DISEASES  OP  THE  ABDOMEN. 


/   ON 

i— - 


DISEASES  OF  THE  ABDOMEN, 


COMPRISING  THOSE  OF  THE 


STOMACH,  AND  OTHER  PARTS  OF  THE  ALIMENTARY 

CANAL,  (ESOPHAGUS,  C^CUM,  INTESTINES, 

AND  PERITONEUM. 


^ 


BY 


Sf  O.  HABERSHCW,  M.D.,  LOOT)., 

FELLOW  OF  THE  ROTAL  COLLEGE  OF  PHYSICIANS  ;    SENIOR  PHYSICIAN  TO,  AND  LATE  LECTURER 
ON  THE  PRINCIPLES  AND  PRACTICE  OF  MEDICINE  AT  OUY'S  HOSPITAL,  ETC. 


WITH    ILLUSTRATIONS. 


SECOND  AMERICAN 


THIRD  ENLARGED  AND  REVISED  ENGLISH  EDITION. 


PHILADELPHIA: 

NKY     O.     LEA. 

1879. 


-  A  vuo 

\V  V I  4,  o 
\ 


COLLINS,    PRINTER. 


PREFACE. 


DISEASES  of  the  Stomach  have,  during  the  last  few  years,  received 
considerable  attention,  and  our  medical  literature  has  been  enriched 
by  the  labors  of  Budd,  Hand  field  Jones,  Chambers,  Brinton,  Wilson 
Fox,  Leared,  Fenwick,  and  others.  Much,  however,  still  remains  to 
be  done;  and  whilst  some  of  the  facts  contained  in  the  present 
volume  will  tend  to  confirm  what  is  already  known,  other  new  ones 
will  be  found,  which,  we  trust,  will  repay  an  attentive  perusal  of  its 
pages. 

The  design  in  this  work  has  been  to  illustrate  the  diseases  treated 
upon,  by  cases  which  have  come  under  our  personal  observation, 
with  a  few  remarks  upon  them,  and  some  general  deductions. 
During  the  period  of  my  curatorship  of  the  Museum  at  Guy's,  and 
of  my  demonstratorship  of  Morbid  Anatomy  for  several  years,  very 
numerous  opportunities  were  presented  of  noticing  diseases  of  the 
stomach  and  intestines  in  their  varied  phases;  and  I  would  tender 
sincere  thanks  to  those  of  my  colleagues  who  have  permitted  the 
mention  of  instances  under  their  care.  Although  I  have  sought 
definitely  to  distinguish  some  classes  of  diseased  conditions,  I  should 
be  very  unwilling  to  regard  them  as  entities  superadded  to  the 
human  frame,  but  rather,  to  quote  the  words  of  Sir  John  Forbes, 
"as  new  phases  of  vital  manifestations." 

Life  may  be  considered  as  the  resultant  of  certain  forces,  mani- 
fested in  the  performance  of  functions,  which  are  combined  harmo- 
niously for  one  purpose;  it  has  received  varied  appellations,  each 
indicative  of  our  inability  to  discover  its  real  character ;  thus  we 
have  had  vital  force,  power  of  growth,  nutrition,  development, 
organization,  nature,  &c.,  each  new  observer  considering  himself 
more  clear-sighted  than  his  predecessor,  although  he  has  merely 
substituted  one  term  for  another.  This  living  force  is  in  close  cor- 
relative relation  with  other  physical  forces,  and  the  fuller  investiga- 
tions of  physiological  science  show  that  the  same  forces  are  in 
operation,  namely,  gravitation,  chemical  action,  &c.,  in  the  living 


VI  PREFACE. 

organism,  as  external  to  it;  modified,  it  is  true,  by  another  force, 
namely,  life.  And  as  in  the  science  of  physics  generally,  so  in  the 
study  of  living  phenomena,  we  must  ever  bear  in  mind  that  a  like 
cause  always  produces  a  like  effect.  Vague  observation,  and  the 
superficial  remarks  of  some  writers,  would  lead  us  to  suppose,  that, 
in  living  phenomena,  the  same  cause  is  followed,  at  first  by  one 
effect,  then  by  another;  interpreting  fixed  realities  by  prejudice 
rather  than  by  reason. 

Some  phraseology  is  necessary  to  express  our  meaning  and  ideas, 
and  one  great  difficulty  is  overcome,  if  we  can  understand  that  the 
same  words  convey  to  each  the  same  thought.  It  may  be  con- 
venient, as  we  have  mentioned,  to  regard  life  as  the  resultant  of 
certain  forces,  and  disease  as  a  deviation  from  the  normal  direction. 
If  any  of  the  forces  which  are  in  natural  operation  be  modified  in 
intensity,  a  deviation  is  the  result,  and  diseased  action  is  produced, 
the  resultant  being  necessarily  changed;  still  the  tendency  is  such 
that  on  the  withdrawal  of  the  modifying  force,  the  normal  course  is 
reassumed.  Not  only  may  it  be  natural  force  which  has  led  to  this 
departure  from  the  healthy  state,  but  new  force  may  be  added,  as 
much  as  when  the  earth  in  its  orbit  is  disturbed  by  the  attraction  of 
some  other  celestial  body. 

In  diseases,  many  sources  of  change  arise — modifying  forces — thus 
syphilitic  or  miasmatic  poison,  small-pox,  &c.,  alter  the  character  of 
every  function;  a  new  substance  is  added  as  much  as  in  the  voltaic 
battery,  when  the  fluid  in  one  or  other  cell  is  changed  by  the  ad- 
mixture of  any  substance;  this  may  be  merely  of  the  kind  already 
existing,  or  a  foreign  substance  may  have  been  introduced ;  in  any 
case,  the  phenomena  are  modified.  Such,  to  some  extent,  is  the  case 
in  pathological  changes.  These  changes,  produced  by  perverted 
nutrition,  or  altered  vital  forces,  are  in  many  instances  of  such  a 
character,  that  no  examination  of  the  structure  itself  could  discern 
the  state  which  had  been  produced;  as  fruitless  would  it  be  to  search 
in  the  nerve  of  a  limb  for  the  altered  force  which  had  led  to  spasm, 
as  to  expect  to  find  a  telegraphic  message  by  a  microscopical  exami- 
nation of  the  wire,  although  the  structure  of  both  had  been  tran- 
siently modified  by  the  disturbance  of  the  forces  they  transmitted. 
If  the  character  of  the  disturbance  in  disease  is  one,  which,  like  a 
polar  force,  reverts  to  its  former  condition,  no  trace  can  be  found  on 
inspection,  but,  in  many  instances,  obvious  structural  modifications 
are  the  result. 

Diseased  action,  however,  as  generally  manifested,  is  the  resultant, 
not  of  one,  but  of  several  changes  in  the  normal  condition,  and  very 


PREFACE.  vii 

few  persons  are  literally  in  perfect  health.  The  living  forces  are 
modified  by  hereditary  tendency,  as  struma;  to  this,  perhaps,  is 
added,  syphilis,  to  that  miasm;  still  further,  sudden  changes  of  tem- 
perature, improper  supply  of  nourishment,  of  heat,  and  light,  may 
be  causes  of  disease ;  each  of  these  may  act  as  fresh  sources  of  devia- 
tion from  the  normal  healthy  direction  of  living  action,  superadded 
to  the  resultant  production  by  the  previous  combination. 

Some  have  supposed  that  acute  disease  quickly  passes  off,  and 
that  with  the  subsidence  of  the  more  marked  symptoms  no  trace  is 
left  behind,  but  very  generally  this  is  not  the  case ;  the  attentive 
study  of  pathology  will  soon  convince  us  of  the  contrary ;  new  ex- 
citing causes  of  disease  arise,  perhaps  of  a  different  character,  but 
the  resultant  (to  revert  to  the  previous  phraseology  of  forces)  is  not 
precisely  the  same,  the  former  diseased  state  acts  as  a  modifying 
force.  This  course  may  be  often  repeated,  and  if  the  changes  have 
been  such  as  to  entail  discomfort  or  weakness,  chronic  disease  is  said 
to  exist;  but  if  without  these,  the  patient  generally  passes  for  one 
in  sound  health.  It  is  the  acumen  of  the  practical  physician  that 
detects  the  traces  of  previous  morbid  action,  and  he  alone  knows 
how  rightly  to  estimate  the  course  likely  to  be  assumed  by  any  new 
addition  to  a  state  widely  diverse  to  that  of  health ;  hence,  also,  the 
variety  of  diseases  by  which  the  same  organ  is  affected,  the  causes 
are  different  and  so  of  necessity  their  effect. 

It  is  the  province  of  medical  science,  rightly  to  estimate  the 
effects  produced  on  vital  action  by  any  disturbing  causes,  and  to 
study  their  almost  endless  varieties;  several  general  characters  lead 
us  to  group  these  effects  into  classes ;  and  although  in  this  volume 
we  have  spoken  of  diseased  action  as  manifesting  itself  especially  in 
the  alimentary  canal  in  the  changes  described,  and  the  symptoms 
detailed,  it  will  be  found  that  these  parts  are  in  many  cases  only 
affected  in  common  with  the  whole  economy,  whilst  in  others,  that 
the  special  manifestation  of  morbid  action  is  in  the  abdomen. 

Numerous  means  are  available  for  checking  and  modifying  dis- 
eased action,  and  we  must  protest  against  the  ignorance  of  those  who 
regard  the  draught  of  medicine  as  the  only  important  agent.  The 
skill  of  the  physician  is  often  most  manifest  in  the  suggestion  of 
hygienic  measures  which  by  many  may  be  assumed  as  of  trifling 
moment ;  and  whilst  it  is  perfectly  true  that  many  morbid  conditions 
cease  after  a  time,  or  that  the  frame  becomes  so  accustomed  to  per- 
verted action  that  the  balance  of  functions  is  apparently  maintained 
without  cognizance  on  the  part  of  the  patient,  still  the  aid  of 
medical  science  is  most  important.  The  first  agents  to  which  we 


Vlll  PREFACE. 

must  refer  are  those  which  are  in  constant  operation  in  the  mainte- 
nance of  life — in  one  state  preservation  of  health,  in  another  the 
cause  of  disease — as  the  character  of  the  air  breathed,  whether 
saturated  with  moisture,  poisoned  with  miasm,  or  with  the  decom- 
posing effluvia  of  crowded  cities,  as  compared  with  that  found  in 
more  elevated  situations,  on  the  sea  or  its  coasts,  &c. ;  so  also  with 
reference  to  diet,  to  light,  to  clothing,  to  temperature ;  to  habits  of 
mental  or  bodily  training  or  exercise ;  the  right  use  of  all  these  is 
not  less  important  in  the  restoration  to  health,  than  in  the  mainte- 
nance of  it,  and  in  both  cases  alike,  is  within  the  province  of  medical 
science. 

Too  frequently  medicine  is  taxed  to  obviate  the  disease  whilst  its 
cause  is  pertinaciously  adhered  to.  It  is  in  vain  to  recommend  to 
the  dyspeptic  patient  remedies  which  would  certainly  mitigate  his 
disease,  whilst  intense  anxiety  remains,  and  hurried,  half-masticated 
meals  are  taken  at  irregular  hours  and  without  due  moderation— 
or,  again,  it  is  useless  to  direct  means  to  relieve  a  disturbed  brain, 
whilst  excitement  is  added  to  excitement,  the  senses  stimulated  by 
light,  noise,  animated  conversation,  and  active  thought — or  to  give 
opium  to  check  peritonitis,  to  quiet  muscular  movement,  when  the 
patient  is  allowed  to  move  from  the  recumbent  position. 

The  consideration  of  the  fundamental  conditions  of  life  demands 
strict  attention,  not  only  as  indicating  the  tendency  vital  action  has 
to  assume  its  natural  direction,  but  also  in  enabling  us  to  use  and 
apply  effective  means  for  the  removal  of  morbid  processes ;  and  we 
are  at  no  great  loss  to  understand  the  intellectual  power  and  acumen 
of  those  who,  because  everything  is  not  known  in  the  pathology 
and  treatment  of  disease,  would  contemptuously  discard  that  which 
is  known  and  established.  We  deplore  the  ignorance  of  those  who 
know  not  the  value  of  opium  in  peritonitis,  &c.,  of  iodide  of  potas- 
sium in  secondary  syphilis,  of  purgatives  and  mercurials  in  hepatic 
engorgement,  of  preparations  of  steel  in  many  forms  of  anaemia,  of 
quinine  and  arsenic  in  intermittents;  our  object  is  not  to  confute 
errors  which  arise  from  wilfully  closing  the  eye  to  light  already 
attained,  but  to  seek  to  add  facts  upon  which  science  may  safely 
advance. 

"We  have  generally  divided  the  chapters  according  to  the  anato- 
mical divisions,  rather  than  in  a  strictly  pathological  manner.  The 
first  chapter  is  on  diseases  of  the  Mouth  and  Throat,  and  the  next 
on  those  of  the  Pharynx,  but  I  have  not  dwelt  upon  those  maladies 
which  more  especially  come  under  the  care  of  the  Surgeon.  The 
chapter  on  disease  of  the  (Esophagus  contains  many  interesting 


PREFACE.  ix 

cases,  some  of  them  obscure  in  their  pathology,  and  very  insidious 
in  their  origin ;  some  instances  of  ulceration,  perforating  the  trachea 
or  bronchi,  which  we  have  described,  have  generally,  and  we  believe 
incorrectly,  been  considered  as  instances  of  cancerous  disease.  The 
diseases  of  the  stomach  constitute  the  subject  of  the  next  section, 
and  have  obtained  from  authors  very  considerable  attention;  we 
believe  that  there  are  forms  of  ulceration,  superficial  and  evanescent, 
which  leave  scarcely  more  trace  in  the  mucous  membrane  of  the 
stomach  than  the  aphthous  ulceration  of  the  mucous  membrane  of 
the  mouth,  whilst  others  are  permanent,  and  are  manifest  after 
death ;  and  indeed  we  find  the  same  forms  of  diseased  action  in  the 
mouth  as  in  the  stomach;  thus  both  are  affected  by  inflammatory 
congestion,  perverted  epithelial  growth  and  secretion,  sluggish  con- 
dition of  the  circulation,  acute  inflammatory  disease,  as  well  as  by 
fibroid  and  cancerous  disease.  Ulceration  of  the  stomach  is  probably 
a  more  common  condition  than  is  generally  supposed,  and  in  many 
instances  yields  to  judicious  treatment;  the  instances  we  have 
adduced  show  that  there  are  several  distinguishing  marks  by  which 
it  may  be  known  from  cancer.  Fibroid  degeneration  of  the  pylorus 
has  generally  been  considered  as  of  a  cancerous  nature ;  and  whilst 
we  are  unable  to  remove  this  almost  certainly  fatal  form  of  disease, 
we  may,  as  in  cancer,  do  much  to  mitigate  the  symptoms  and  to 
prolong  life. 

In  the  so-called  functional  disease  of  the  stomach,  chemical  re- 
search has  removed  much  that  was  obscure,  and  will  do  still  more 
to  explain  the  pathological  changes  which  are  induced;  the  investi- 
gation of  the  physiological  connections  of  the  pneumogastric  nerve, 
as  well  as  of  the  sympathetic  nerve  and  the  branches  of  the  semi- 
lunar  ganglia,  will  enable  us  more  correctly  to  estimate  the  very 
diverse  symptoms  produced  in  dyspepsia,  many  of  which  have  their 
origin  in  this  source.  The  right  estimate  of  such  symptoms  as  pain 
in  the  region  of  the  stomach  and  vomiting  are  most  important  in 
the  diagnosis,  and  equally  so  in  the  treatment  of  gastric  affections. 

The  chapter  on  the  Duodenum  presents  us  with  instances  of  dis- 
ease which  closely  simulate  maladies  of  the  pyloric  extremity  of  the 
stomach. 

The  next  chapter  is  on  Gastro-Enteritis  and  Enteritis,  diseases  in 
which  correct  diagnosis  is  very  important;  in  the  latter  class  of 
diseases  especially,  life  may  be  easily  sacrificed  by  time  being  thrown 
away,  and  by  improper  treatment;  in  the  former  with  judicious  diet, 
warmth,  demulcents,  &c.,  recovery  generally  takes  place.  Whilst 
we  strongly  recommend,  in  many  of  these  instances  of  gastro-ente- 


X  PREFACE. 

ritis,  the  avoidance  of  mercurials,  the  value  of  salines,  as  bicarbonate 
and  chlorate  of  potash,  and  carbonate  of  soda,  are  well  known  to 
those  who  have  carefully  watched  the  effect  that  has  followed  their 
administration. 

In  the  chapter  on  Strumous  Disease  of  the  Intestine  and  Perito- 
neum we  have  sought  to  show  that  these  diseases  are  only  part  of  a 
general  perverted  nutrition,  and  that,  in  many  instances,  disease  in 
other  organs  is  entirely  obscured  by  the  more  marked  affection  of 
the  abdominal  viscera;  here,  also,  we  should  strongly  urge  the 
avoidance  of  mercurial  medicines  and  of  drastic  purgatives;  the 
lives  of  many  delicate  children  are  sacrificed  by  worm  powders  and 
quack  nostrums  administered  in  these  diseases. 

The  diseases  of  the  Cascum  and  its  Appendix  are  next  dwelt  upon. 
We  have  shown  that  unusual  freedom  of  the  cascal  attachments  may 
determine  intestinal  obstruction  from  rotatory  movements  of  the 
intestine;  the  symptoms  and  treatment  of  csecal  distension  and  of 
local  enteritis  are  described,  as  well  as  the  more  serious  consequences 
of  perforation  of  the  appendix;  we  have  given  numerous  instances 
of  these  forms  of  affection,  and  their  perusal  will  show  the  great 
similarity  in  the  symptoms  and  their  general  course.  Dr.  Burns, 
in  a  valuable  paper  in  the  'Medico-Chirurgical  Transactions,'  de- 
scribed, several  years  ago,  some  of  these  affections.  It  would  appear 
that  the  symptoms  of  cancerous  disease  of  the  caecum  are  different 
from  simple  csecal  enteritis  and  perforation ;  and  that  in  many  cases 
we  may  discriminate  the  character  of  the  complaint.  It  will  be 
found  that  treatment  may  do  much  to  relieve  and  to  assist  the  cure 
of  caecal  disease ;  the  pain  demands  rest,  and  it  is  well  after  the  acute 
pain  has  subsided,  still  to  maintain  absolute  repose  for  several  days. 
The  bowels  are  often  confined,  but  the  use  of  purgatives  generally 
aggravates  the  disease  without  effecting  the  desired  operation ;  this 
is  better  obtained  by  the  application  of  warmth  and  by  opium; 
those  remedies  which  diminish  the  enteric  inflammation  lead  most 
speedily  to  the  subsidence  of  the  morbid  symptoms. 

We  have  next  pointed  out  the  characters  of  the  several  forms  of 
Diarrhoea,  but  we  are  well  aware  that  diarrhoea  is  merely  a  symptom 
of  very  different  conditions,  and  that  in  many  instances  it  passes 
almost  imperceptibly  into  dysentery. 

Dysentery  and  Catarrh  of  the  Colon  are  the  subjects  afterwards 
considered,  and  the  instances  we  have  adduced  show  that  inflamma- 
tion of  the  colon,  of  a  most  severe  form,  arises  in  our  own  country. 
Most  of  the  writers  on  this  subject  are  those  who  have  observed  it 
in  its  worst  forms  abroad  or  in  Ireland.  In  some  of  the  cases 


PREFACE.  xi 

typhoid  fever  was  simulated;  in  others,  perforation  of  the  colon  had 
taken  place;  in  one  there  was  pyaemia  and  commencing  suppuration 
in  the  liver;  in  several  chronic  cases  the  secondary  effects  were 
shown  in  producing  contraction  of  the  intestine,  perforation,  and 
artificial  anus,  &c. ;  as  regards  abscess  in  the  liver,  in  one  case  the 
abscess  had  dried  and  contracted;  in  another,  fresh  diseased  action 
was  set  up  around  it,  and  abscess  in  the  brain  was  the  result.  We 
must  confess,  that  in  some  of  the  most  severe  forms  all  treatment  is 
ineffectual  to  cure,  whilst  it  partially  soothes  and  relieves;  but  in 
the  great  majority  of  instances  means  may  be  used  which  effectually 
combat  the  symptoms  of  disease. 

We  had  intended  to  give  some  observations  on  Asiatic  cholera, 
but  for  several  reasons  have  not  done  so ;  first,  because  although 
the  disease  manifests  itself  more  apparently  in  the  disturbed  func- 
tions of  the  alimentary  canal,  it  has  not  been  clearly  shown  that  the 
disease  is  really  one  affecting  alone  or  even  principally  the  abdomen ; 
and  secondly,  all  the  facts  known  in  reference  to  this  disease  are 
better  and  more  clearly  given  in  the  report  drawn  up  by  Dr.  Baly 
and  Sir  W.  Gull. 

In  the  chapter  on  Typhoid  Fever,  we  have  merely  described  the 
condition  of  the  abdominal  affection,  without  entering  into  the  gene- 
ral question  of  fever,  and  its  treatment ;  in  the  latter,  it  is  well  to 
guard  against  the  danger  of  so  freely  administering  opiates  to  check 
diarrhoea  as  to  lead  to  cerebral  oppression,  and  excessive  engorge- 
ment of  the  lungs,  from  imperfect  performance  of  the  respiratory 
function. 

In  the  chapter  on  Colic  I  have  cursorily  spoken  of  the  simpler  forms 
of  the  disease,  and  separated  the  more  severe  varieties  of  ileus- 
internal  strangulation,  intussusception,  and  cancerous  disease  of  the 
colon.  It  will  be  found  that  whilst  the  latter  conditions  bear  a 
strong  general  resemblance  in  producing  fatal  constipation,  they 
may,  in  many  instances,  be  distinguished  the  one  from  the  other ; 
intussusception  closely  simulates  simple  colic,  but,  in  not  a  few  in- 
stances, it  is  accompanied  by  discharge  of  bloody  mucus,  or  with 
actual  diarrhoea ;  and  this  latter  symptom  sometime  arises  even  with 
cancerous  disease  of  the  sigmoid  flexure.  We  have  very  strongly 
urged  the  avoidance  of  drastic  purgatives,  calomel,  colocynth,  and 
even  milder  purgatives,  and  as  strongly  recommended  the  free  ad- 
ministration of  opium ;  the  cases  detailed  almost  uniformly  show 
that,  where  purgatives  were  given,  vomiting,  pain,  and  distress  were 
increased,  whilst  these  and  other  symptoms  were,  on  the  contrary, 
relieved  by  opium.  Opium,  in  such  cases,  appears  to  be  the  best 


Xll  PREFACE. 

means  of  procuring  relief  to  the  bowels,  if  an  action  be  possible.  In 
the  chapter  on  Worms,  we  have  designedly  been  very  brief  in  our 
remarks. 

The  cases  of  Suppuration  in  the  Abdominal  Parietes,  and  of  Per- 
foration of  the  Intestine  from  Without,  are  an  interesting  series ; 
many  of  them  are  obscure  in  their  diagnosis,  and  different  in  their 
course.  Great  care  is  required  in  watching  the  symptoms  as  they 
become  fully  developed,  and  in  avoiding  the  aggravation  of  them  by 
too  active  treatment. 

The  serous  membrane  of  the  intestines,  the  peritoneum,  is  so  in- 
timately connected  with  the  morbid  conditions  of  the  alimentary 
canal,  that  we  have  appended  some  remarks  on  its  diseases.  In 
very  many  instances  the  serous  membrane  is  implicated  by  direct 
extension  of  disease ;  in  other  cases,  the  peritoneal  change  is  the 
expression  of  a  general  morbid  condition  of  the  whole  system ;  in 
addition  to  a  chapter  on  Peritonitis,  I  have  appended  remarks  on 
Ascites,  and  also  on  Abdominal  Tumors. 

The  cases  I  have  recorded  might  have  been  given  at  greater  length, 
and  on  each  one  fuller  remarks  might  have  been  made ;  but  the  de- 
sign of  the  work  has  been,  in  a  very  few  words  to  point  out  the 
peculiarities  of  each  instance,  embodying  in  more  general  deductions 
the  apparent  conclusions  derived  from  the  whole.  My  desire  is  to 
shed  some  light  on  the  difficulties  which  often  present  themselves  in 
the  daily  practice  of  the  profession,  and  to  suggest  means  whereby 
the  alleviation  of  disease  may  be  promoted. 

The  former  editions  of  my  work  on  '  Diseases  of  the  Abdomen' 
have  been  exhausted  for  several  years,  and  I  regret  that  so  long  a 
time  has  elapsed  in  the  preparation  of  the  present  edition.  The 
whole  work  has  been  carefully  revised ;  several  chapters  on  impor- 
tant subjects  have  been  added ;  and,  I  trust,  that  it  will  be  found 
helpful  in  clinical  study,  as  well  as  in  the  treatment  of  disease.  I 
have  derived  valuable  assistance  from  my  friend  and  colleague,  Dr. 
Goodhart,  both  in  examining  the  later  records  of  the  Guy's  patho- 
logical department,  and  also  in  the  revision  of  the  work. 


70,  BROOK  STREET, 

GROSVENOR  SQUARE. 


TABLE  OF  CONTENTS. 


CHAPTER  I. 

Introduction. — Digestion  and  Indigestion  contrasted;  general  remarks  upon  and 
summary  of  the  various  Structures  involved — glandular,  muscular,  serous,  con- 
necting, nervous,  vascular ;  preliminary  remarks  upon  Treatment ;  the  action 
of  Remedies  modified  by  the  condition  of  the  recipient ;  by  the  co-existence  of 
other  independent  Diseases — The  antagonism  of  Disease  .  .  .1 7-25 

CHAPTER  II. 

On  Diseases  of  the  Tongue  and  Mouth. — Paralysis  of  the  Tongue — Deficient  Epi- 
thelium— Irregular  growth  of  the  Papillae — Stomatitis — Thrush  —  Ulcerative 
Stomatitis — Cancrum  oris — Glossitis,  acute  and  chronic — phthisical  and  syphi- 
litic; Xeuralgia  of  the  Tongue  —  Spasm  —  Ringworm — Parotitis — Tonsillitis, 
acute  and  chronic — (Edema — Cancer — Paralysis  of  the  Soft  Palate — Bulbar 
Paralysis  . >  26-44 

CHAPTER  III. 

On  Diseases  of  the  Pharynx. — Spasm — Inflammation,  catarrhal,  membranous, 
phlegmonous — Syphilitic  ulceration — Cancer — Suppuration  behind  the  Pharynx, 
Cysts,  and  Pouches •  .  •  .  45-52 

CHAPTER  IV. 

On  Diseases  of  the  (Esophagus. — Anatomical  relations — Diseases  of  the  Mucous 
Membrane— Inflammation— Ulceration — Abscesses— Cysts— Warty  Growths- 
Muscular  Spasm  —  Paralysis  —  Hypertrophy — Dilatation — Pouches — Strictures 
—The  effects  of  Corrosives— Foreign  bodies— Hemorrhage  in  the  Coats — 
Rupture— Gastric  Solution 53-112 

CHAPTER  V. 

On  Organic  Disease  of  the  Stomach.—  Post-mortem  Solution— Atrophy  of  the 
Mucous  Membrane — Hypertrophy— Mammillation— Dilatation  of  Stomach — 
Hour-glass  contraction  —  Lardaceous  Disease— Inflammation  —  Ulceration  — 
Sloughing  of  the  Mucous  Membrane— Fibroid  Degeneration  of  the  Pylorus- 
Polypoid  growths— Cancer  113-208 


XIV  TABLE    OF    CONTENTS. 


CHAPTER  VI. 

On  Functional  Diseases  of  the  Stomach. — Forms  of  Dyspepsia,  from  altered  condi- 
tions of  the  Mucous  Membrane  and  of  the  Gastric  Juice — Atonic  Dyspepsia — 
Exhaustion  of  Cerebro- Spinal  System  of  Nerves — Dyspepsia  in  Chronic  Disease 
— At  different  periods  of  life — Excessive  Secretion  of  Gastric  Juice — Irregular 
Secretion — Morbid  Secretion — Pyrosis — Dyspepsia  in  Rheumatism  and  Gout ; 
in  Albuminuria — Dyspepsia  from  altered  Vascular  Supply ;  from  the  state  of 
the  Nervous  System  ;  from  impeded  movements  of  the  Stomach  ;  from  Fermen- 
tation ;  Haematemesis — Pain  and  Vomiting  as  signs  of  Gastric  Disease. 

209-251 

CHAPTER  VII. 

On  Diseases  of  the  Duodenum. — Position  of — State  of  Secretion — Malformation — 
Congestion,  acute  and  chronic — Duodenal  Dyspepsia — Inflammation — Ulcera- 
tion — Cancerous  Disease — Mechanical  Obstruction — Hydatid — Perforation  • 

252-275 

CHAPTER  VIII. 

On  Muco- Enteritis  and  Enteritis. — Varieties — Pathological  Changes — Symptoms — 
Diagnosis — Prognosis — Treatment 276-288 

CHAPTER  IX. 

On  Strumous  and  Tubercular  Disease  of  the  Alimentary  Canal.  Lardaceous  Dis- 
ease.— Various  forms  of  Diarrhoea  in  Strumous  Children — Disease  of  Mesenteric 
Glands — Tubercles  in  the  Peritoneum  and  Strumous  Peritonitis — Disease  of 
Intestine  in  Phthisis — Lardaceous  Disease 289-311 


CHAPTER  X. 

On  Diseases  of  the  Caecum  and  Appendix  Cceci. — Changes  in  position — Atrophy — 
Distension — (Edema — Congestion — Typhlitis — Ulceration  —  Cancerous  Disease 
— Trichocephalus  Dispar. — Appendix  —  Increase  of  length — Atrophy — Dilata- 
tion— Concretions  —  Results  of — Symptoms  of  Disease  —  Diagnosis — Prognosis 
— Causes — Treatment — Cases  .  ....  312-345 


CHAPTER  XI. 

On  Diarrhoea. — Varieties  of — Bilious — Catarrhal — Dysenteric — Choleraic — Serous 
— Melaena — Symptoms — Causes — Prognosis — Diagnosis — Treatment — Cases 

346-359 

CHAPTER  XII. 

On  Dysentery  and  Catarrhal  Inflammation  of  the  Colon. — Morbid  Anatomy  of 
Dysentery — Sequelae — Symptoms — Causes — Prognosis — Diagnosis — Treatment 
— Table  of  Cases — Chronic  Catarrh  of  the  Colon  360-392 


TABLE    OF    CONTENTS.  XV 


CHAPTER  XIII. 

On  Typhoid  Disease  of  the  Intestine. — Changes  in  the  Intestine — Symptoms  — 
Treatment — Cases 393-397 

CHAPTER  XIV. 

On  Colic. — Varieties — Flatulent  Colic — Spasmodic  Colic — Colic  from  Food — from 
retained  Secretions  and  Excretions — Lead  Colic — Symptoms  and  Diagnosis — 
Treatment 398-406 

CHAPTER  XV. 

On  Constipation. — Effects — Causes — Symptoms — Diagnosis — Treatment      407-420 

CHAPTER  XVI. 

On  Organic  Obstruction,  Internal  Strangulation,  Intussusception  and  Carcinoma 
of  Intestine. — Classification  of — Causes — Symptoms — Diagnosis — Treatment — 
Cases  of 421-472 

CHAPTER  XVII. 

On  Suppuration  of  the  Abdominal  Parieties,  Perforation  of  the  Intestine  from  with- 
out, and  Abscess  in  the  Abdominal  Parieties,  extending  into  the  Intestine — 
Fecal  Abscess. — Causes  of  External  Perforation — Symptoms — Treatment — 
Cases  of 473-486 

CHAPTER  XVIII. 

On  Intestinal  Worms. — Varieties — Symptoms — Treatment      .         .         .     487-494 

CHAPTER  XIX. 

On  Peritonitis. — Pathological  Changes — Varieties — Symptoms — Chronic  Peritonitis 
— Diagnosis — Prognosis — Causes — Treatment — Cases — Loose  Bodies  in  Perito- 

O  O 

neum 495-515 

CHAPTER  XX. 

On  Ascites.  Dropsy.— Varieties— Asthenic— Mechanical— Inflammatory— Glandu- 
lar— Tubercular — Cancerous — Ovarian — Symptoms — Diagnosis — Treatment 

516-529 

CHAPTER  XXI. 

On  Abdominal  1  "umors.— Abdominal  Spaces— Tumors  found  in  each  region— Diag- 
nostic Signs 530-537 


ON 


DISEASES  OF  THE  ALIMENTARY  CANAL 


CHAPTEE    I. 

INTRODUCTION 

THE  function  of  digestion  is  essentially  connected  with  life  and 
health ;  and  slight  deviations  from  its  normal  performance  produce 
suffering  in  a  greater  or  less  degree.  He  is,  indeed,  fortunate  who 
can  pass  through  his  daily  duties  without  having  the  thoughts  and 
attention  directed  to  those  operations  for  the  solution,  absorption, 
and  assimilation  of  nourishment,  which  in  health  are  completed 
unconsciously,  without  attention,  or  sense  of  pain.  If  there  be  severe 
derangement  of  the  digestive  functions,  not  only  is  the  attention  di- 
rected to  them,  and  discomfort  entailed,  but  there  is  reaction  upon 
the  higher  capabilities  of  man's  nature  ;  the  energies  of  the  brain  are 
enfeebled,  the  memory  is  defective,  the  will  vacillates,  and  the  intel- 
lectual powers  are  less  free  to  guide  in  daily  duty,  avocation,  and 
research.  The  strength  and  muscular  movements  are  diminished, 
and  the  enjoyment  of  life  changes  to  daily  suffering  and  anxiety. 
Contrast  the  vigor  of  mind  and  body  during  health,  with  the  enfeebled 
energy  of  the  dyspeptic  and  hypochondriac.  In  the  former  state 
there  is  no  impediment  to  the  exercise  of  deep  thought  and  labor,  in 
any  sphere  to  which  the  mind  may  be  directed ;  the  whole  attention 
in  the  latter  is  absorbed  by  those  functions,  which  are  at  best  only 
subservient  to  the  manly  exercise  of  mind  and  will. 

If  the  digestive  process  be  altogether  checked,  and  no  new  supply 
of  nourishment  be  absorbed  and  assimilated;  if  no  restoration  be 
made  to  the  waste  entailed  by  the  exercise  of  every  function,  life 
must  sooner  or  later  cease ;  and  disease,  in  its  ravages,  presents  few 
spectacles  more  distressing  to  witness,  than  the  gradual  wasting  of 
the  frame,  and  cessation  of  life  itself,  from  the  non-supply  of  food. 
Thus  the  whole  system  sympathizes  with  disorder  of  the  alimentary 
canal. 

A  knowledge  of  the  structure  and  functions  of  each  part  of  the 

digestive  apparatus,  is  necessary  for  the  right  comprehension  of  its 

diseases.     The  structures  of  the  alimentary  canal  are  various,  and 

their  sympathies  universal;  but  in  health  these  are  so  combined  as 

2 


18  INTRODUCTION. 

to  form  a  beautiful  and  harmonious  whole:  thus,  1st,  we  find  a  mu- 
cous membrane  richly  supplied  with  glands,  lining  the  alimentary 
canal  throughout  its  course;  these  glands  are  for  secretion  and  excre- 
tion; the  secretions  from  these  act  physically  or  chemically  in  the 
digestive  process,  whilst  the  excretory  glands  separate  noxious  or 
effete  principles  from  the  blood.  2d.  Beneath  the  mucous  is  the 
muscular  coat,  essential  for  the  execution  of  the  required  movements, 
and  for  the  propulsion  of  the  contents  of  the  canal.  3d.  The  peri- 
toneal or  serous  covering,  which  by  its  smoothness  permits  of  the 
movement  of  one  portion  of  the  intestine  upon  another,  and  allows 
distension  to  take  place.  4th.  The  binding  tissues,  which  are  found 
between  these  previously  mentioned  tunics,  and  which  support  other 
equally  essential  parts,  namely,  5th,  the  bloodvessels  and  lymphatics ; 
and,  6th,  the  nerves  supplied  by  the  sympathetic  and  cerebro-spinal. 
As  Abercrombie  has  remarked,  in  reference  to  diseases  of  the  sto- 
mach, so,  also,  it  may  be  added,  in  reference  to  every  part  of  the 
alimentary  canal;  that  for  the  proper  performance  of  the  function  of 
digestion,  the  mucous  membrane  must  be  in  health,  the  secretions 
normal,  the  supply  of  blood  and  of  nervous  energy  such  as  is  required, 
and  the  movements  free.  It  must,  however,  be  borne  in  mind  that 
the  alimentary  canal  contains  substances  which  are,  strictly  speaking, 
external  to  the  living  agency  and  beyond  the  control  of  animal  life; 
and  that  those  chemical  forces,  which  we  lind  in  operation  external 
to  the  body,  act  in  the  same  manner  within  the  stomach  and  small 
and  large  intestines:  the  food  becomes  dissolved  when  the  same 
solvents  are  provided,  and  other  circumstances  adapted,  as  to  tempe- 
rature, movements,  &c.,  whether  it  be  put  in  a  phial  or  in  the  stomach. 
The  fermentation  of  its  contents  takes  place  in  the  stomach  and  canal, 
as  well  as  in  any  chemical  receiver;  and  these  facts  have  to  be 
remembered  in  the  study,  as  well  as  in  the  treatment,  of  disease. 
Chemical  force  is  in  operation  throughout  the  whole  animal  economy ; 
it  is  modified  and  controlled  by  the  living  power,  or  it  is  free  to  act  alone. 

Each  of  the  parts  which  have  been  mentioned,  may  be  alone  dis- 
eased, or  all  conjointly  ;  the  symptoms  arising  from  each  are  in  some 
cases  distinct,  in  others  we  cannot  separate  the  one  from  the  other. 

1st.  The  mucous  membrane  and  its  secretions.  The  derangement 
of  these  constitutes,  perhaps,  the  greater  part  of  the  milder  ailments 
of  the  alimentary  canal.  The  symptoms  vary  according  to  the  part 
affected  :  in  the  stomach,  producing  some  of  the  forms  of  dyspepsia ; 
in  the  intestines,  constipation,  diarrhoea,  &c.  But,  when  the  mucous 
membrane  alone  is  affected,  it  appears  probable  that  pain  is  not  pro- 
duced, and  this  circumstance  we  must  regard  as  a  merciful  arrange- 
ment. The  lining  membrane  is  exposed  to  varied  causes  of  irritation, 
but  we  do  not  experience  pain ;  if  such  were  the  case,  every  portion 
of  undigested  food  might  produce  suffering ;  in  some  cases  severe 
pain  is  found  in  indigestion,  but  this  arises  from  an  extreme  sensi- 
bility of  the  sympathetic  and  other  nervous  supply  of  the  stomach, 
&c.,  and,  is  not  due  to  the  mucous  membrane  alone. 

Dr.  Beaumont,  in  his  observations  on  the  stomach  of  Alexis,  some- 
times observed  the  mucous  membrane  dry,  injected,  and  much  irri- 


INTRODUCTION.  19 

tated  without  the  production  of  pain;  so,  also,  I  have  observed 
actual  inflammation  of  the  stomach,  as  found  in  cases  of  poisonin^ 
by  oxalic  acid,  by  chloride  of  zinc,  and  even  by  arsenic,  without  pain 
from  first  to  last. 

2d.  The  muscular  coat  we  find  so  stimulated,  that  it  rapidly  con- 
tracts, and  impels  onwards  its  contents ;  or,  it  is  so  enfeebled  as  to 
retain  them;  sometimes  it  is  spasmodically  contracted,  or  a°-ain 
dilated,  as  in  the  forms  of  colic  and  flatulent  distension.  These  con- 
ditions appear  to  be  productive  of  pain,  sometimes  of  a  very  intense 
form  as  we  find  in  the  griping  of  colic,  and  in  enteritis,  &c.  As  long 
as  the  peristaltic  action  is  uniform,  regular,  and  healthy,  we  are  un- 
conscious of  the  movement ;  but  as  soon  as  it  becomes  irregular  or 
tumultuous,  retarded  or  spasmodic,  we  are  sensible  of  uneasiness,  or 
even  of  severe  pain ;  the  muscular  coat  of  the  intestine  is  probably 
excited  to  contraction  by  the  direct  stimulus  of  its  contents,  but  the 
harmony  of  its  movements  is  due  to  the  supply  of  nervous  influence 
which  it  receives. 

3d.  The  peritoneal  or  serous  investment  also  manifests  its  derange- 
ment by  pain ;  and  here,  again,  is  a  wise  provision,  for  as  its  disorders 
require  rest,  or  rather  an  absence  of  movement  of  the  coils  of  intes- 
tine one  upon  another,  and  the  pain  of  peritoneal  disease  is  increased 
by  muscular  exertion,  so  the  patient  becomes  prompted  to  assume 
that  position,  and  to  retain  that  state,  which  is  the  best  suited  for 
the  restoration  from  disease.  The  observant  pathologist  and  physi- 
cian know,  practically,  the  importance  of  rest  in  the  recumbent 
position,  and  they  follow  the  teaching  of  nature  in  their  stringent 
directions :  by  this  means  inflammation  is  localized,  and  when  per- 
forations of  the  intestine  have  taken  place,  the  injury  is  limited  and 
life  may  be  prolonged. 

4th.  The  state  of  the  investing  or  binding  tissues ;  and,  5th,  the 
supply  of  blood,  are  important  considerations  in  the  study  of  these 
diseases  of  the  intestine.  The  connective  tissue,  for  instance,  is  in 
some  cases  the  seat  of  fatal  malady,  in  constriction  of  the  pylorus, 
and  in  cancer.  Still  more  does  the  supply  of  blood  call  for  attention  : 
it  may  be  in  excess,  as  in  active  or  passive  hyperasmia;  in  pulmo- 
nary, cardiac,  and  hepatic  diseases  the  engorgement  of  the  mucous 
membrane  leads  to  peculiar  and  characteristic  symptoms;  the  rupture 
of  vessels,  or  ulceration  into  them,  causes  hemorrhage  into  the  canal ; 
and  again,  a  scanty  supply  or  depraved  condition  of  blood  prevents 
the  proper  performance  of  digestioii,  as  after  great  hemorrhage,  in 
over-lactation,  in  purpura,  scurvy,  or  in  starvation.  The  appearance 
of  the  blood  discharged  into  the  several  portions  of  the  canal  greatly 
differs ;  thus,  in  disease  of  the  stomach,  it  is  generally  ejected  as 
dark  semi-coagulated  blood ;  sometimes,  as  in  the  latter  stages  of 
cancer,  as  coffee  ground  substance ;  or  in  the  acute  disease  of  the 
stomach  and  duodenum,  according  to  Dr.  Fraser  and  others,  as  a 
green  fluid.  If,  however,  blood  be  passed  into  the  duodenum,  and 
discharged  per  rectum,  it  has  a  black  and  tarry  character;  and  in 
proportion  as  the  source  of  the  discharge  is  near  or  more  distant 
from  the  rectum,  a  sanguineous  appearance  is  retained. 


20  INTRODUCTION. 

(Hh.  The  state  of  the  nervous  supply  is  often  lost  sight  of;  this 
is  a  most  complicated  system  of  nervous  fibrils  and  ganglia,  which 
are  intimately  connected  with  the  cerebro- spinal  centres,  and  with 
the  ganglionic  centres  of  other  parts,  as  of  the  lungs,  the  heart,  and 
the  uriuo-genital  organs.  Many  of  the  signs  of  intestinal  disease 
arise  from  this  cause,  and  they  have  been  dwelt  upon  by  various 
authors.  In  the  '  Guy's  Hospital  Reports'  of  1856,  I  have  described 
some  dissections  and  observations  on  this  supply  of  nerves ;  they 
surround  the  vessels,  are  distributed  with  them,  and  reach  every 
part  of  the  intestine.  The  sympathy  of  other  organs  in  abdominal 
disease  is  due  to  this  supply.  In  indigestion,  we  find  cephalalgia, 
depression  of  spirits,  impaired  mental  energy,  disordered  sensations 
of  general  or  special  sense ;  and  all  these  arise  from  the  connection 
of  the  sympathetic  and  the  cerebro-spinal  nerves.  So  again,  the 
throbbing  of  the  vessels,  the  excited  or  irregular  action  of  the  heart 
in  dyspepsia,  proceed  from  the  union  of  the  cardiac  ganglia  with  the 
solar  plexus  of  nerves.  With  the  lungs,  the  kidneys,  the  uterus,  we 
notice  similar  sympathetic  disturbance ;  and  oftentimes,  in  a  most 
marked  manner,  the  skin  is  observed  in  close  connection  with  the 
internal  mucous  membrane ;  this  disorder  of  the  alimentary  canal 
induces  many  forms  of  cutaneous  eruption,  as  urticaria  from  partak- 
ing of  mussels ;  or  the  more  chronic  diseases  of  psoriasis,  eczema,  £c. 
These  sympathies  may,  however,  be  due  to  the  vascular  condition, 
as  well  as  to  the  nervous  relation,  of  one  structure  with  another. 
This  relationship  of  parts,  however,  sometimes  acts  in  a  reverse 
direction ;  the  alimentary  canal  is  affected  secondarily,  from  disease 
of  other  structures ;  for  example,  vomiting  is  a  symptom  of  disease 
of  the  brain,  of  the  kidney,  and  of  the  uterus.  But  beside  these, 
there  appear  to  be  symptoms  of  primary  disease  of  the  alimentary 
canal,  which  are  due  directly  to  the  sympathetic  nerve.  1.  A  re- 
markable depression  of  the  pulse,  which  we  often  find  in  these  dis- 
eases of  the  abdomen,  when  the  pulse  becomes  soft  and  compressible, 
and  often  irregular.  2.  A  sense  of  sinking  and  exhaustion  is  one 
of  the  most  marked  signs  of  abdominal  disease ;  and  in  some  cases 
this  exhaustion  leads  to  sudden  death,  not  only  in  cases  when  a 
person  may  have  died  from  a  blow  on  the  epigastrium,  but  in  other 
instances.  I  remember  the  case  of  a  man  suffering  from  aneurism 
of  the  descending  aorta;  he  endured  very  severe  pain,  and  the  pulse 
became  much  enfeebled ;  in  a  few  days  he  died  with  comparative 
suddenness.  On  examination,  an  aneurism  of  the  aorta  was  found 
at  the  diaphragm  ;  it  had  led  to  absorption  of  the  bodies  of  the 
vertebrae,  but  there  had  been  no  extravasation  of  blood  into  the 
peritoneum,  the  cellular  tissue,  nor  into  other  parts.  The  aneurismal 
sac  was  about  four  inches  in  length,  and  one  and  a  half  in  height ; 
it  had  pushed  aside  the  pillars  of  the  diaphragm,  which  were  white 
and  degenerated ;  the  splanchnic  nerves  were  stretched  across  the 
sac,  and  the  semi-lunar  ganglion  was  pushed  considerably  forward 
and  pressed  upon.  I  think  we  were  justified  in  believing  that  in 
this  case  the  depression,  and  comparatively  sudden  death,  were  in 
great  measure  due  to  the  pressure  on  the  great  sympathetic  nerve 


INTRODUCTION.  21 

centre  of  the  abdomen.  I  bave,  also,  often  observed  in  cases  of 
gastritis  from  poisons,  as  arsenic,  sulphuric  acid,  chloride  of  zinc, 
oxalic  acid,  that  the  pulse  becomes  remarkably  depressed;  and 
sometimes,  where  we  might  have  been  led,  from  the  absence  of  pain 
and  other  symptoms,  to  have  given  a  favorable  prognosis,  the  patient 
has  suddenly  died. 

The  pneu mo-gastric  nerve  has  an  important  influence  on  the 
stomach.  This  was  shown,  in  a  marked  degree,  by  the  experiments 
of  Dr.  Wilson  Philip,  who  demonstrated  the  effect  of  section  of  the 
pneumo-gastric  nerve  on  digestion,  in  checking  its  progress  :  section 
does  not,  however,  completely  prevent  but  only  for  a  time  checks  the 
secretion  of  gastric  juice.  The  irritation  of  the  gastric  branches  of 
the  pneumo-gastric  sometimes  leads  to  symptoms  indicative  of  disturb- 
ance of  the  pulmonary  branches  of  the  same  nerve :  cough  may  be 
set  up ;  and  it  is  probable  that  the  converse  takes  place ;  the  pul- 
monic  branches  may  cause  reflex  influence  on  the  stomachic  branches, 
and  produce  violent  vomiting.  In  the  'Medical  Times  and  Gazette,' 
there  is  a  very  interesting  paper  by  Mr.  J.  Hutchinson  on  the  "  Dys- 
pepsia of  Phthisis;"  and  many  have  found  in  the  early  stage  of 
phthisis  that  the  power  to  digest  food  is  impaired,  the  diminished 
nutrition  tending  greatly  to  promote  the  formation  of  low  organized 
products  in  the  lungs. 

Not  only  do  the  signs  of  abdominal  disease  arise  from  the  derange- 
ment of  the  structures  of  the  canal,  and  from  changes  in  the  secre- 
tions and  contents  of  the  same,  but  the  administration  of  remedies 
is  guided  by  similar  considerations.  Many  may  be  led  to  the  use 
of  means  by  mere  empiricism,  but  the  observations  of  Chambers, 
Turnbull,  Budd,  Handfield  Jones,  Wilson  Fox,  Pavy,  &c.,  suggest 
a  more  scientific  and  correct  treatment,  by  directing  to  the  physio- 
logical chemistry  of  digestion  or  to  a  more  correct  pathology. 

Remedies  may  be  classed  in  the  following  manner : — 

1.  Those  agents  which  are  used  to  check  fermentative  and  chemi- 
cal action. 

2.  Those  which  remove  offending  or  injurious  materials,  and  ex- 
creta. 

3.  Those  which  correct  or  improve  the  secretions  from  the  mucous 
membrane,  or  those  poured  into  the  canal. 

4.  Those  which  affect  the  muscular  coat,  and  its  movements. 

5.  Those  which  alter  the  state  of  the  circulation  and  vessels  or  ab- 
sorbents. 

6.  Those  which  act  on  the  abdominal  sympathetic  nerve. 

7.  Those  which  promote  the  solution  of  food  and  the  digestive 
process. 

Dr.  Headland  has  directed  attention,  in  his  valuable  essay  on  the 
action  of  medicines,  to  their  mode  of  operation,  considering  them 
chemically  or  mechanically,  prior  to  absorption  ;  then,  after  entering 
the  blood*  as  influencing  either  its  constituents  or  the  muscular  or 
nervous  structures  to  which  it  is  supplied  ;  and  lastly,  in  their  elimi- 
nation from  the  body.  These  remarks  forcibly  apply  to  the  action  of 
agents  in  the  treatment  of  abdominal  disease.  It  is,  however,  often 


22  INTRODUCTION. 

lost  sight  of,  that  Avhilst  the  alimentary  canal  is  the  structure  by 
which  remedies  can  be  most  easily  made  to  enter  the  blood,  and  there 
exert  their  curative  influence,  it  may  be  in  such  a  condition  from 
morbid  changes,  that  no  absorption  can  take  place  ;  and  the  adminis- 
tration of  remedies  by  the  stomach  may  become  almost  useless,  as  far 
as  regards  their  ultimate  action  after  absorption. 

1.  Agents  which  are  used  to  check  fermentative  action  or  chemi- 
cal decomposition. 

Chemical  science  has  done  much,  and  will  do  still  more,  to  suggest 
means  of  counteracting  changes  of  this  character.  Dr.  Turnbull  has 
dwelt,  in  his  work,  on  the  varied  forms  of  fermentative  action,  and 
has  shown  that  some  agents  possess  in  this  manner  considerable 
power:  as  carbolic  acid,  creasote,  sulphurous  acid  and  sulphites,  char- 
coal, so  also  alcohol,  &c.  We  have  had  much  to  learn  on  this  sub- 
ject ;  and  it  would  well  repay  the  labor  of  some  one  well  versed  in 
chemical  science  to  extend  these  researches. 

2.  As  agents  for  the  expulsion  of  injurious  matters,  or  excreta,  AVC 
have  the  whole  class  of  emetics,  of  laxatives,  of  purgatives,  and  the 
different  forms  of  enemata. 

3.  Other  remedies  change  the  character  of  the  secretions  from  the 
mucous  membrane,  for  the  mucus  in  the  canal  is  sometimes  of  an  irri- 
tating character,  and  we  may  do  much  to  change  its  state  after  secre- 
tion, at  the  same  time  that  we  use  means  to  prevent  such  abnormal 
secretion  from  taking  place :  demulcents  of  the  following  kind,  as  milk, 
arrowroot,  gum  acacia,  linseed,  sheath  the  mucous  membrane  ;  whilst 
lime  water,  chalk,  solution  of  potash,  carbonate  of  soda,  lessen  the 
irritating  character  of  the  secretion.     At  the  same  time,  to  diminish 
inflammatory  congestion,  other  agents  are  called  for,  as  ipecacuanha, 
potash,  soda,  magnesia,  and  some  of  their  salts,  or  mercurials,  anti- 
mony, &c.     If  the  object  is  to  correct  secretions  arising  from  an  en- 
feebled or  relaxed  state  of  the  membrane,  we  have  vegetable  and 
mineral  astringents  and  tonics,  mineral  acids,  &c. ;  others  stimulate 
to  greater  secretion,  when  there  is  deficiency,  as  some  irritants,  ipe- 
cacuanha, salt,  capsicum,  pepper,  &c. 

4.  Among  remedies  which  act  on  the  muscular  movements  of  the 
intestine,  I  may  enumerate  the  class  of  purgatives,  magnesia,  nux 
vornica,  and  strychnia,  as  increasing  peristaltic  action  ;  and  conium, 
opium,  henbane,  as  diminishing  these  intestinal  movements. 

5.  The  state  of  the  vessels  of  the  stomach  is  affected  by  remedies 
which  directly  act  upon  the  portal  circulation ;    thus,  purgatives, 
mercurials,  &c.,  by  unloading  the  bowels,  relieve  the  tension  of  the 
vessels. 

(x  Those  which  act  on  the  sympathetic  nerve,  diminishing  its 
sensibility,  are  chloroform,  hydrocyanic  acid,  opium,  bismuth,  oxide 
and  nitrate  of  silver ;  those  tending  to  increase  its  sensibility  are 
steel,  quinine,  vegetable  and  mineral  tonics,  alcohol,  &c. 

7.  Remedies  which  promote  the  solution  of  food  are  hydrochloric 
acid,  nitro-hydrochloric  acid;  pepsine  and  several  compounds  which 
contain  it  are  regarded  as  powerful  assistants  to  digestion. 

These  remedies  are  variously  combined  in  the  treatment  of  abdo- 


INTRODUCTION.  23 

minal  disease;  and  by  combination  their  action  is  modified,  or  their 
efficiency  is  increased;  their  presence  may  thus  be  better  tolerated, 
and  their  absorption  be  facilitated. 

The  dietetic  regimen  is  one  of  the  most  important  subjects  in 
diseases  of  the  stomach  and  intestine;  as  in  other  visceral  diseases 
we  cannot  obtain  rest  of  the  affected  organ,  but  we  can  shield  it  from 
unnecessary  irritation  and  fresh  excitement. 

It  will,  often,  however,  be  found,  that  the  state  of  the  nervous 
system  modifies  the  effect  of  remedies.  If  a  highly  sensitive  patient, 
hysterical  or  hypochondriacal,  be  led  to  suppose  that  a  medicine  will 
produce  a  certain  effect,  the  mind  is  so  directed  and  influenced,  that 
a  powerful  action  may  be  produced;  or,  if  a  patient  firmly  believe 
that  a  particular  medicine  or  plan  of  treatment  will  do  him  injury, 
we  shall,  in  all  probability,  find  that  the  symptoms  are  described  as 
greatly  aggravated  thereby,  and  no  argument  will  remove  this  per- 
suasion. Thus,  in  a  patient  who  had  suffered  from  hemiplegia,  and 
was  in  a  nervous  condition,  but  who  could  not  be  persuaded  to  dis- 
continue medicine,  two  tablespoonfuls  of  spring  water  were  followed 
by  violent  purging,  and  when  changed  for  a  pill  of  bread  the  same 
effect  was  produced;  and  nothing  could  induce  her  to  take  a  second 
pill.  Sbe  believed  them  to  be  powerfully  aperient,  and  purging  took 
place.  Hence  a  wide  field  is  opened  for  the  charlatan  and  the  quack; 
while  the  experienced  practitioner  often  finds,  that  in  many  ailments 
he  will  in  vain  prescribe  remedial  agents,  unless  he  acquire  the 
confidence  of  the  patient. 

The  connection  of 'one  disease  with  another  is  a  subject  of  great 
importance,  and  of  much  interest  to  the  practical  physician.  We 
rarely  find  that  a  patient  has  died  free  from  all  disease,  except  the 
one  which  has  been  the  immediate  cause  of  death;  such  a  case  is, 
indeed,  exceptional.  It  may  be  that  an  acute  inflammation  of  the 
lungs  has  led  to  fatal  results,  whilst  chronic  disease  may  have  been 
going  on  in  the  abdomen,  the  heart,  or  the  brain,  perhaps  quite  in- 
dependently, but  having  an  important  influence  on  the  curability  or 
non-curability  of  the  acute  attack:  chronic  disease  creeps  along  with 
unobserved  step,  till  some  acute  affection  proves  fatal.  This  relation 
of  disease  is  worthy  of  our  consideration,  in  studying  the  affections 
of  the  alimentary  canal;  and  we  may  find  that  the  diseased  condi- 
tions arrange  themselves  in  the  following  manner:— 

1.  They  take  place  simultaneously  in  the  same  body,  without  any 
connection,  as  mere  coincidents. 

2.  The  connection  may  be  that  of  different  manifestations  of  the 
same  disease  in  its  progressive  action,  rather  than  a  really  different 
diseased  condition. 

3.  One  disease  may  have  important  modifying  or  predisposing 
influence  upon  another. 

4.  Several  organs  may  be  affected  simultaneously  by  one  exciting 
cause. 

5.  One  disease  may  be  antagonistic  to  another:  and, 

6.  Diseases  or  abnormal  conditions  are  conservative,  or  preventive 
from  other  maladies. 


24  INTRODUCTION. 

I  might  enumerate  many  instances  of  these  associations,  in  diseases 
of  the  nervous  system,  or  of  the  thoracic  viscera,  but  must  content 
myself  with  a  few  illustrations  from  disease  of  the  abdomen. 

1.  As  instances  of  coincident  disease  we  may  mention  the  follow- 
ing:— A  patient  who  had  been  employed  in  working  lead,  and  was 
affected  with  severe  colic,  was  partially  relieved;  but  he  suddenly  had 
intense  collapse,  and  died  with  all  the  symptoms  of  perforated  intes- 
tine.    We  found,  on  inspection,  that  there  was  in  the  stomach  a 
large  chronic  ulcer,  and  at  its  base  a  minute  perforation,  which  had 
extended  into  the  peritoneal  cavity.     A  child  affected  with  chorea 
was  relieved  by  sulphate  of  zinc,  and  was  about  to  go  home,  when  it 
was  seized  with  severe  dysentery  during  the  time  that  cholera  pre- 
vailed; and  the  little  patient  died  in  three  days.     In  another  patient 
who  lately  died  under  my  care,  affected  with  phthisis,  we  found  a 
large  hydatid  cyst  close  ito  the  kidney,  in  addition  to  advanced  de- 
generation of  the  lungs.     These  diseases  could  not  be  looked  upon 
as  cause  and  effect,  and  were  correctly  regarded  as  coincidents. 

2.  As  manifestations  of  the  same  disease  in  progressive  action,  and 
which  ought  not  to  be  considered  as  two  but  as  one  disease,  we  may 
enumerate    the    sympathetic  vomiting  which   we   find   in   hydro- 
cephalus,  and  in  diseases  of  the  kidney  and  uterus ;  the  diarrhoea  in 
albuminuria,  which  follows  an  anasarcous  condition  of  the  mucous 
membrane;  the  constipation  in  diseased  spine;  and  the  extension  of 
strumous  disease,  one  organ  or  viscus  after  another  becoming  affected, 
as  the  intestine  and  the  larynx  in  phthisis.     So,  again,  the  severe 
neuralgic  pain  in  the  parietes  of  the  abdomen,'  simulating  colic,  but 
arising  from  disease  of  the  spine,  may  be  only  the  early  manifes- 
tations of  the  spinal  disease,  though  preceding  its  more  marked  indi- 
cations by  several  months  or  years.     Numerous  instances  might  be 
adduced  in  the  progressive  symptoms  of  spinal  disease,  or  of  valvular 
disease  of  the  heart,  or  of  chronic  disease  of  the  lungs. 

3.  One  disease  predisposes  to,  or  modifies  another  disease.     Thus, 
in  affections  of  the  lungs,  of  the  heart,  and  of  the  liver,  the  circula- 
tion through  the  vena  portae  may  become  exceedingly  impeded,  and 
the  whole  of  the  mucous  membrane  engorged  and  turgid  with  blood ; 
in  this  stage,  a  slight  exciting  cause  will  set  up  distressing  flatulence 
and  distension  of  the  abdomen;  chronic  catarrh  of  the  mucous  mem- 
brane is  produced,  or  hemorrhage,  or  ulceration.     A  patient  in  inci- 
pient phthisis,  with  tubercles  or   slight  ulceration  in  the  mucous 
membrane  of  the  intestine,  is  exposed  to  cold  and  wet,  to  hardship 
and  miasm.  and  very  severe  diarrhoea  or  dysentery  is  set  up ;  whilst 
his  friend,  who  has  had  no  such  predisposing  cause,  escapes,  though 
exposed  to  the  same  exciting  influence. 

The  instances  which  Dr.  Budd  has  deduced,  of  abscess  in  the  liver 
following  ulceration  of  some  part  of  the  tract  of  the  canal  which 
supplies  the  vena  portae,  are  also  illustrations  of  one  diseased  state 
exciting  another;  here  it  does  not  follow  as  a  necessary  sequence,  or 
a  continuance  of  the  same  diseased  action,  but  new  morbid  changes 
are  produced. 

Again :    a  strumous  subject,  after  recovery  from  typhoid  fever, 


INTRODUCTION.  25 

may  become  affected  with  tubercular  disease  of  the  intestine.  The 
previous  exhaustion  lias  rendered  the  patient  already  of  feeble 
power,  subject  to  another  disease  ;  and  the  typhoid  ulceration  of  the 
intestine  is  sufficient  to  excite  the  manifestation  of  its  action :  these 
are  by  no  means  rare  occurrences. 

A  sailor  was  admitted  into  Guy's,  a  few  years  ago,  with  Asiatic 
cholera.  He  died,  and  in  his  colon  a  large  circumscribed  ulcer  was 
found,  about  the  size  of  a  crown  piece,  and  covered  by  a  slough, 
with  adherent  cherry-stones ;  the  presence  of  such  irritation  and  in- 
flammation in  the  colon  would  render  him  more  amenable  to  an 
attack  of  the  disease,  although  it  would  not  produce  it. 

A  young  man  fell  into  the  Thames,  and  afterwards  was  seized 
with  diarrhoea ;  he  was  shortly  attacked  with  typhoid  fever,  and 
admitted  into  Guy's.  He  quickly  died;  the  dysenteric  diarrhoea 
rendered  the  fever  more  severe  in  its  character ;  and  perhaps  was  the 
immediate  cause  of  the  fatal  termination. 

4.  Two  diseases  sometimes  arise  from  the  same  exciting  cause,  or 
rather  two  organs  become  affected  :  thus,  acute  inflammation  of  the 
colon  sometimes  comes  on  with  pneumonia.     Of  these  cases  we  shall 
speak  more  fully  in  our  remarks  on  dysentery. 

5.  Diseases  are  in  some  instances  antagonistic.     Cancerous  disease 
and  struma  appear  to  be  in  this  relation ;  or  it  may  be  that  they  are 
so  diverse  in  their  mode  of  operation  that  they  cannot  exist  together. 
We  sometimes  find  in  cancerous  disease  of  the  abdomen  that  the 
mesenteric  glands  are  contracted,  and  calcareous,  as  the  result  of  old 
strumous  change ;  this  evidently  indicates  that  one  mode  of  action 
has  given  place  to  another  of  a  different  kind  ;  and  the  same  kind  of 
deposit  is  occasionally  found  in  the  lung  when  cancerous  disease  has 
proved  fatal. 

6.  Disease  may  be  conservative  in  its  character.     We  have  many 
instances  of  this  in  the  abdomen.     A  chronic  ulcer  of  the  stomach  is 
oftentimes  prevented  by  adhesions  from  perforating  the  peritoneal 
sac,  so  that  the  liver,  or  the  pancreas,  forms  the  base  of  the  ulcer. 
So,  again,  in  ulceration  of  the  ileum  and  colon,  in  disease  of  the 
cascum,  and  in  gall-stone,  adhesions  prevent  extravasation,  or  limit 
it  after  it  has  taken  place.     Many  instances  of  this  kind  might  be 
adduced  in  which  life  has  been  prolonged  by  these  adhesions. 

These  associations  of  disease  have  an  important  bearing  on  the 
correct  diagnosis,  and  still  more  on  the  prognosis,  of  disease ;  they 
may  oftentimes  serve  to  explain  its  intractable  character,  as  well  as 
to  account  for  the  different  effect  of  remedies  under  apparently  similar 
circumstances;  and  the  complication  of -disease  should  place  us  on 
our  guard  in  making  close  observation  of  every  sign  which  presents 
itself  to  us,  and  should,  lead  to  a  strict  inquiry  into  the  history  of 
the  patient,  and  the  previous  ailments  to  which  he  may  have  been 
subject. 


26 


CHAPTER  II. 

ON  DISEASES  OF  THE  TONGUE  AND  MOUTH. 

THE  unqualified  acceptance  of  the  commonly  received  opinion, 
that  the  state  of  the  tongue  is  a  guide  to  the  condition  of  the  diges- 
tive organs  would  lead  us  into  many  mistakes ;  and  it  is  therefore 
important  to  know  to  what  extent  the  appearances  of  the  tongue 
will  serve  us  in  the  investigation  of  abdominal  disease.  It  gives 
valuable  indications,  1st  in  regard  to  the  general  state  of  the  whole 
system,  and  2dly  as  to  the  condition  of  particular  parts  or  organs. 
Thus  the  growth,  or  the  state  of  nutrition  of  the  body  generally  may 
be  seen  in  the  condition  of  the  epithelium  of  the  tongue  ;  the  furred 
state  of  the  surface  may  show  a  febrile  condition  of  system ;  and  as 
nutrition  as  a  whole  is  checked  it  becomes  dry  and  brown,  and  even 
black ;  or  the  alterations  may  be  of  a  merely  local  character,  as  from 
inflammatory  disease  of  the  mouth  alone,  or  a  partial  fur  may  be  due 
to  contact  with  a  carious  tooth,  or  there  may  be  papillary  hyper- 
trophy from  persistent  local  irritation. 

But  the  tongue  is  a  complex  organ,  and  its  morbid  condition  may 
be  connected  with  alterations  in  any  one  of  its  different  structures ; 
it  is  composed  of  several  vessels  and  nerves  ;  it  receives  a  large  sup- 
ply of  vessels,  and  has  a  complex  epithelial  investment. 

In  reference  to  the  muscular  condition  of  the  tongue  we  may  find 
that  one  side  of  the  tonyue  is  wasted  and  paralyzed,  whilst  the  other 
side  is  plump  and  strong ;  this  state  is  found  in  paralysis  of  the  hy- 
poglossal  nerves,  it  was  well  marked  in  a  patient  under  my  care  in 
Guy's  Hospital  some  years  ago ;  the  breast  had  been  removed  two 
years  previously  for  cancer,  and  disease  of  the  brain  subsequently 
supervened,  there  was  severe  pain  at  the  back  of  the  head,  and  the 
side  of  the  tongue  was  irregularly  flaccid  and  flabby,  whilst  the  other 
was  strong  and  active.  After  death  a  small  growth  was  found 
directly  implicating  the  origin  of  the  ninth  nerve.1  Mr.  Hilton2  has 
also  drawn  attention  to  the  effect  of  disease  implicating  the  second 
or  third  divisions  of  the  fifth  nerve  in  producing  furring  of  the  side 
of  the  tongue. 

2d.  One  side  of  the  tongue  may  be  weakened  as  in  ordinary 
hemiplegia;  the  tongue  is  protruded  to  the  opposite  or  weakened 
side  by  the  increased  action  of  the  sound  side. 

3d.  The  tongue  is  protruded  slowly  in  cases  of  general  weakness 
and  paralysis;  or — 

1  An  interesting  case  of  this  kind  is  published  by  Sir  James  Fagot  in  the  '  Clin. 
Soc.  Trans.,'  vol.  iii,  p.  238.  A  man,  set.  27,  injured  the  back  of  his  head,  and  part 
of  the  foramen  magnum  became  necrosed,  and  coincidently  half  of  the  tongue  wasted. 
Recovery  ensued  on  the  removal  of  the  bone. 

*  '  Rest  and  Pain,'  p.  194  et  seq. 


ON  DISEASES  OF  THE  TONGUE  AND  MOUTH.         27 

4th.  The  patient  may  be  quite  unable  to  move  it  from  extreme 
exhaustion.  The  organ  remains  at  the  floor  of  the  mouth  in  a 
powerless  state. 

5th.  The  opposite  condition  is  found  in  cases  of  chorea,  the  tongue 
is  sharply  protruded  and  as  quickly  drawn  in,  as  if  from  spasmodic 
action,  reminding  one  of  the  movements  of  the  tongue  of  the  frog, 
or  of  the  chameleon. 

6th.  The  tongue  is  sometimes  pale  and  flabby,  and  indented  with 
the  markings  of  the  teeth,  indicating  its  want  of  tone  and  muscular 
contractility ;  or  we  find  it  small  and  contracted,  and  the  tip  almost 
drawn  to  a  point,  as  in  irritability  of  the  nervous  system. 

In  reference  to  the  vascular  condition,  the  tongue  is  pale  in  states 
of  ansemia,  but,  on  the  contrary,  in  hyperaemia  it  is  red  and  injected, 
a  state  which  may  be  especially  noticed  at  the  tip  and  edges;  it  is 
this  condition  which  is  found  in  irritable  states  of  the  intestinal 
tract,  and  in  enteric  fever.  The  red  and  distinct  appearance  of  the 
papillae  of  the  tongue,  as  observed  in  states  of  angina  and  scarlet 
fever,  indicate  active  hypergemia;  whilst,  in  diseases  of  the  lungs 
and  heart  producing  obstruction  of  the  circulation  and  imperfect 
aeration  of  the  blood,  the  venous  condition  of  the  tongue  induces  a 
passive  hyperaemia  or  lividity. 

The  epithelium  of  the  tongue  undergoes  constant  change  of  waste 
and  repair;  its  growth  may  be  checked  as  that  of  other  cellular 
structures,  and  it  may  be  reproduced  with  great  rapidity;  it  may  be 
scarcely  developed  at  all,  or  when  produced,  degenerative  changes 
may  quickly  ensue.  To  these  various  changes  in  the  epithelial  coat 
are  due  the  different  kinds  of  fur,  and  a  furred  tongue  is  generally 
caused  by  the  excessive  formation  of  the  epithelial  coat,  and  the 
consequent  degeneration  of  the  redundant  cells.  But  although  an 
overgrown  epithelium  is  the  common  anatomical  basis  of  a  furred 
tongue,  there  may  be  considerable  difference  in  the  characteristics  of 
color  and  tlfickness,  association  with  papillary  enlargement,  growth 
of  fungus,  &c.,  serving  to  distinguish  various  states  of  systemic  and 
abdominal  disease. 

With  regard  to  the  causes  of  the  changes  of  color  noticed  on  the 
tongue,  but  little  is  known  beyond  the  fact  that  a  brown  or  yellow 
color  is  in  great  part  caused  by  decomposition  of  epithelial  growth 
or  of  food,  saliva,  mucus,  &c.,  in  the  mouth,  and  therefore  may  be 
independent  of  any  derangement  of  the  viscera.1 

The  white  tongue  of  the  febrile  state,  and  the  white  creamy  fur  of 
acute  rheumatism,  depend  probably  upon  some  alterations  of  the 
secretions  acting  upon  the  epithelial  coat.  Allied  to  these  is  the  so- 
called  strawberry  tongue  of  scarlet  fever  differing  only  in  the  addi- 
tional enlargement  of  the  fungiform  papillae  and  their  projection  from 
the  surface.  This  state  has  been  said  to  be  only  part  of  a  general 
disease  of  stomach  although  always  present  in  scarlet  fever.2 

1  Wilson  Fox  states  that  a  large  proportion  of  the  colored  furs  are  produced  by 
slight  hemorrhages  from  the  gums. — '  Dis.  of  Stomach,'  p.  19. 

2  Femvick,  "On  the  Condition  of  the  Stomach  and  Intestines  in  Scarlatina,"  '  Med.- 
Chir.  Trans.,'  vol.  xlvii,  p.  210.     In  this  paper  Dr.  Fenwick  attempts  to  show  that 


28  ON    DISEASES    OF    THE    TONGUE    AND    MOUTH. 

Browness  of  the  tongue  is  found  in  states  of  exhaustion  and  is 
sometimes  denominated  the  "Typhoid"  tongue;  the  fallacy  of  brown 
discoloration,  from  coifee,  tobacco,  or  liquorice,  &c.,  must  always  be 
borne  in  mind.  The  Mack  tongue  arises  from  a  more  complete  state 
of  exhaustion,  and  still  further  degeneration;  with  it  sordes  are  ob- 
served on  the  gums  and  teeth,  the  surface  becomes  irregular  and  fis- 
sured. The  later  stages  of  severe  fever  present  us  with  this  change. 

We  sometimes  find  deficient  epithelial  growth  ;  there  is  then  a 
scanty  fur,  and  this  is  often  associated  with  injection  of  the  sub- 
stance of  the  tongue ;  there  is  weakness,  with  irritation  of  the 
mucous  membrane.  In  this  state  a  "patchy"  condition  is  often  ob- 
served, and  when  there  is  still  further  loss  of  power,  with  irritation, 
a  red  beef-like  tongue,  which  may  assume  a  glazed  appearance,  is 
found,  as  in  the  later  stages  of  abdominal  disease,  and  of  phthisis, 
&c.,  sometimes  with  aphthous  secretion  and  with  ulceration.  The 
tongue  becomes  sore,  mastication  is  difficult,  and  deglutition  painful. 
In  the  condition  that  we  shall  presently  have  to  notice  as  chronic 
inflammation  of  the  tongue,  there  is  a  red  and  glossy  appearance ; 
the  whole  of  the  mucous  membrane  appears  raw  and  sore  and  oozing, 
as  if  there  were  an  eczematous  state  of  the  surface. 

The  irregular  growth  of  the  papillte  of  the  tongue  leads  to  warty 
conditions  which  may  be  harmless,  or  the  precursors  of  malignant 
disease.  The  irritation  of  a  decayed  and  roughened  tooth,  when 
long  continued,  may  give  rise  to  excessive  sprouting  of  the  papillary 
structures,  and  present  appearances  with  difficulty  distinguished 
from  cancerous  disease.  The  morbid  growth  of  epithelium,  when 
more  general,  gives  rise  to  an  appearance  which  has  been  called 
"  ichthyosis  of  the  tongue."  This  condition  is  found  not  only  on  the 
tongue  but  also  on  the  inner  surface  of  the  lips  and  cheeks ;  it  con- 
sists of  milk-white  patches,  which  have  a  tough  appearance,  and 
sometimes  are  not  at  all  unlike  white  leather.  It  is  said  to  be  in- 
variably followed  by  cancer,  though  opinions  differ  as  to  its  curability 
in  its  earlier  stages.  All,  however,  are  agreed  as  to  its  exceeding 
intractability,  and  for  this  reason  it  is  of  interest  to  the  physician, 
for  he  will  probably  detect  the  disease  in  its  earlier  stages  and  when 
it  is  more  likely  to  be  amenable  to  treatment.  It  was  first  recorded 
by  Hulke  in  1864,  and  again  accurately  described  by  Bazin  in  1868, 
who  called  it  buccal  psoriasis.1  It  was  considered  by  him  as  a  squa- 
mous  affection  of  the  buccal  mucous  membrane  allied  to  arthritic 
psoriasis  ;2  and  he  states  that,  although  very  intractable,  an  alkaline 
treatment,  local  and  general,  has  produced  some  cures.  It  is  not 

inflammation  of  the  resophagus,  the  stomach,  and  the  intestine  usually  accompanies 
scarlatina  ;  that  desquamation  of  the  epithelium  of  these  parts  takes  place  ;  that, 
notwithstanding  the  anatomical  changes  in  the  stomach,  the  formation  of  pepshie  is 
not  prevented  ;  and  that  in  this  disorder  the  condition  of  the  mucous  membrane  is 
similar  to  that  of  the  skin. 

'  For  a  very  good  account  of  this  disease  see  a  thesis  by  M.  le  Dr.  Dobove,  Paris, 
1873;  alsoFairlie  Clarke,  '  Med.  Chir.  Trans.,' 1874 ;  H.  Morris,  'Brit.  Med.  Journal,' 
1874. 

£  Sir  James  Paget  also  considers  this  to  be  connected  with  gout.  "  See  Lectures  on 
the  Surgical  Aspect  of  Gout,"  'Brit.  Med.  Journal,'  vol.  i,  1875,  p.  737. 


OX  DISEASES  OF  THE  TOXGUE  AND  MOUTH.         29 

unfrequently  associated  with  syphilis,  though  it  is  not  benefited  by 
anti-syphilitic  remedies. 

Stomatitis,  or  inflammation  of  the  mucous  membrane  of  the  mouth, 
is  often  present  in  young  children,  especially  during  weaning.  The 
gums  become  red,  the  mouth  is  hot,  the  tongue  swollen  and°furredr 
with  whitish  covering  and  with  red  papillae  observable  through  it! 
There  is  a  general  febrile  state ;  the  child  becomes  fretful,  and  its 
sleep  is  disturbed.  Other 'portions  of  the  mucous  membrane  may  be 
affected  at  the  same  time  and  symptoms  of  diarrhoea  may  come  on, 
or  severe  irritation  of  the  stomach,  so  that  food  is  at  once  vomited 
or  the  bowels  acted  on  as  soon  as  food  is  taken.  This  state  quickly 
leads  to  exhaustion  and  rapid  emaciation  ;  and  unless  it  is  checked, 
a  fatal  result  may  soon  follow.  It  may  be  produced  by  cold,  by 
improper  food,  by  inattention  to  proper  hygienic  measures,  by  im- 
pure air.  AVe  shall  have  again  to  refer  to  this  condition  in  speaking 
of  inflammation  of  the  stomach. 

As  to  the  treatment  of  stomatitis,  pure  air  and  proper  diet  are 
essential ;  milk  with  lime  water  or  asses'  milk  may  be  tried,  and,  if 
absolutely  necessary,  a  wet  nurse  procured.  Much  relief  may,  how- 
ever, be  afforded  by  medicine ;  chlorate  of  potash  should  be  given 
internally,  and  it  may  be  used  as  a  wash  to  the  rnouth ;  or  borax 
with  honey  may  be  employed,  and  if  the  bowels  are  confined,  a  tea- 
spoonful  of  castor  oil,  or  small  quantity  of  citrate  of  magnesia,  or  of 
rhubarb  and  carbonate  of  soda,  may  be  given. 

This  form  of  disease  is,  however,  not  confined  to  children,  for  in 
adults  we  find  that  the  mucous  membrane  of  the  whole  mouth  be- 
comes inflamed,  extending  backwards  to  the  tonsils  and  fauces,  and 
implicating  the  tongue.  A  person  may  be  exposed  to  cold  or  wet 
or  to  a  fog,  and  be  seized  with  soreness  of  the  mouth  and  throat, 
the  mucous  membrane  becomes  red  and  swollen,  the  tongue  is  en- 
larged, and  sometimes  is  so  much  swollen  that  it  is  protruded  beyond 
the  teeth,  the  throat  is  reddened  and  swallowing  is  difficult.  The 
patient  becomes  very  feverish,  the  temperature  is  raised,  and  there 
is  general  distress.  This  is  not  a  specific  or  contagious  form  of 
malady,  but  appears  to  be  due  to  shock  from  cold;  sometimes  the 
whole  mouth,  at  other  times  only  the  posterior  fauces  and  the  tonsils 
are  affected,  and  we  then  have  acute  tonsillitis,  or  a  condition  which 
is  with  difficulty  distinguished  from  true  and  contagious  diphtheria. 
Acute  stomatitis,  extremely  severe  in  its  onset,  subsides  after  a  few 
days,  with  very  little  treatment  beyond  warmth  and  bland  nutritious 
diet ;  it  is  well  to  act  gently  on  the  bowels  and  to  administer  saline 
medicine,  such  as  the  citrate  of  potash  and  acetate  of  ammonia ;  and, 
if  the  circulation  is  depressed  and  the  pulse  compressible,  then  wine 
and  alcoholic  stimulants  are  called  for. 

In  stomatitis  the  follicles  are  sometimes  especially  affected,  small 
vesicles  are  observed,  round,  transparent,  and  elevated,  and  when 
broken,  leave  an  irregular  gray  surface,  resembling  a  small  ulcer; 
this  condition  is  spoken  of  as  follicular  stomatitis;1  the  mouth  is  pain- 

1  Aphthae  are  considered  by  some  as  vesicules  ;  but  according  to  Bohn,  quoted  by 
Niemeyer,  no  fluid  can  at  any  time  be  obtained  from  them,  and  they  are  rather  croup- 


30  ON    DISEASES    OF    THE    TONGUE    AND    MOUTH. 

ful  and  mastication  interfered  with.  These  vesicles  occur  on  the 
tongue,  on  its  sides,  its  freenum,  on  the  lips,  &c.  The  constitutional 
symptoms  may  be  very  slight,  but  there  is  generally  interference 
with  digestion,  and  the  condition  is  ascribed  to  that  cause.  Whether 
this  be  the  case  or  not,  it  is  generally  associated  with  faulty  nutrition, 
and  may  occur  after  any  of  the  eruptive  fevers.  In  the  treatment  it 
is  well  to  act  gently  on  the  bowels  by  saline  aperients  as  carbonate 
of  magnesia,  dilute  acid  with  sulphate  of  magnesia,  rhubarb  with 
magnesia,  &c.  Salines  may  also  be  advantageously  given  with  bark ; 
a  chlorate  of  potash  gargle  should  be  used,  and  care  be  paid  to  the 
diet,  so  as  to  avoid  food  that  is  likely  to  ferment,  such  as  sugar, 
acescent  fruits,  &c.  The  application  of  caustic,  as  nitrate  of  silver, 
is  often  recommended;  it  relieves  pain  at  the  site  of  the  ruptured 
vesicles,  but  there  is  often  an  increase  in  the  abraded  surface,  and 
greater  subsequent  pain.  If  there  be  impaired  general  health,  it  is 
very  desirable  that  a  change  of  air  to  a  warm  locality  be  tried. 

The  Thrush  or  Muguet  is  a  peculiar  form  of  disease  of  the  mouth 
occurring  in  some  states  of  exhaustion  and  of  chronic  disease.  It 
consists  in  a  white  or  pultaceous  secretion,  which  is  found  either  in 
patches  or  is  generally  diffused  upon  the  mucous  membrane  of  the 
tongue,  the  mouth  and  the  pharynx ;  the  mucous  membrane  is  red, 
and  there  is  tenderness  of  the  surface  and  some  pain  on  movement ; 
the  deep  redness  of  the  mucous  membrane  is  hidden  by  the  thick 
white  or  aphthous  covering;  sometimes  vesicles  are  present,  and  the 
glands  are  enlarged,  and  the  papilke  congested ;  there  is  distress  and 
febrile  disturbance.  The  white  patches  increase  in  size  and  are  re- 
renewed  after  removal.  This  aphthous  condition  occurs  in  young 
children  and  also  in  adults  in  exhausted  states  of  the  system,  as  in 
the  last  stages  of  phthisis ;  it  is  often  looked  upon  as  an  indication  of 
the  approach  of  a  fatal  termination.  It  is  a  disease  which  is  said  to 
have  its  seat  only  on  mucous  surfaces  which  are  covered  by  pave- 
ment epithelium,1  thus  affecting  only  the  mouth,  fauces,  and  oesoph 
agus,  but  it  is  frequently  associated  in  the  severer  cases  with  well- 
rnarked  evidence  of  general  derangement  of  the  intestinal  tract,  and 
it  is  common  to  have  vomiting  and  purging  with  it.  It  is  also  in 
children  very  commonly  followed  by  an  erythematous  or  eczematous 
state  of  the  buttocks  and  genitals.2  Mastication  is  difficult,  and  in 
the  infant  suction  is  painful.  If  the  white  deposit  be  examined  by 
the  microscope  it  is  found  to  consist  of  mucous  cells,  spherical  cells, 
epithelium,  and  sometimes  the  torula  of  the  oidium  albicaus.  The 
torula  is  not  always  present,  and  it  is,  on  the  other  hand,  sometimes 
found  when  the  condition  of  the  mouth  is  only  part  of  a  general  state. 

ous  exudations  on  the  surface  of  the  mucous  membrane,  and  the  disease  is  therefore 
called  croupous  stomatitis  (Nienieyer,  vol.  i,  p.  421).  Rindfleisch,  however  ('Path. 
Histology,'  vol.  i,  §  354,  Syd.  Soc.),  describes  a  vesicular  condition  due  to  serous 
exudation  in  a  membrane  covered  by  scaly  epithelium.  These  vesicles  subsequently 
rupture,  and  a  small  sore  is  formed.  Thus  the  aphthous  state  may  be  considered  as 
the  later  stage  of  the  vesicular. 

1  Trousseau,  'Clinical  Medicine,'  Syd.  Soc.,  vol.  ii,  p.  619. 

2  Valleix,  'Clinique  des  Maladies  des  En  fail  ts  nouveau -lie's.'     Paris,  1838,  chapitre 
Sine. 


ON  DISEASES  OF  THE  TONGUE  AND  MOUTH.        31 

In  the  treatment  of  the  disease,  it  is  most  important  to  improve 
the  general  health  and  sustain  the  strength  ;  the  mucous  membrane 
of  the  mouth  should  be  cleansed  by  a  dilute  solution  of  the  per- 
manganate of  potash,  or  of  borax,  or  of  chlorate  of  potash ;  the  sul- 
phite or  hyposulphite  of  soda  may  be  employed,  3j  to  |j  of  water, 
or  astringent  gargles  of  alum,  catechu  or  oakbark. 

In  Ulcerated  Stomatitis1  we  have  a  more  severe  affection,  which 
unless  it  be  produced  by  mercurial  salivation,  is  especially  seen  in 
young  children  of  from  four  to  ten  years  of  age.  The  gums  become 
red  and  swollen,  and  then  ulcerate ;  they  quickly  assume  a  gray  and 
sloughy  appearance  and  the  alveolar  processes  are  exposed;  they 
readily  bleed,  and  the  ulceration  extends  from  the  gums  to  the 
cheeks.  The  teeth  become  loosened  and  are  lost;  the  submaxillary 
glands  are  enlarged.  The  child,  for  the  disease  is  more  especially 
observed  in  early  life,  is  seen  to  be  pale  and  cachectic,  the  mouth  is 
hot,  and  there  is  a  general  febrile  state ;  but,  even  severe  forms  of 
ulcerative  stomatitis  are  not  usually  associated  with  any  marked 
constitutional  disturbance;  children  do  not  appear  to  be  suffering 
severely,  and  the  pain  during  mastication,  with  swelling  of  the  cheek 
and  with  fetor  and  hemorrhage,  are  the  prominent  symptoms.  The 
cause  of  this  severe  disease  may  generally  be  traced  to  poor  and 
improper  diet  and  to  an  impure  atmosphere ;  sometimes  it  is  attri- 
buted to  mercurial  medicine,  but  it  may  occur  quite  independently  of 
any  such  exciting  cause ;  it  is  more  likely  to  occur  after  exanthems, 
such  as  measles  or  scarlet  fever,  and  it  is  a  wise  precaution  never  to 
administer  mercurial  medicine  to  young  children  during  the  course 
of  or  the  convalescence  from  these  diseases.  In  the  treatment 
nourishing  diet  and  a  pure  air  are  most  important ;  stimulants  are 
advisable,  if  there  be  much  prostration  of  strength.  Chlorate  of 
potash  should  be  used  as  a  wash  and  also  given  internally,  borax 
dissolved  in  glycerine  may  be  applied,  or  a  solution  of  carbolic  acid, 
or  of  permanganate  of  potash,  and  cinchona  bark  or  quinine  should 
be  administered.  If  the  ulceration  assume  a  phagedeenic  form  and 
spread  rapidly,  it  is  well  to  apply  a  strong  solution  of  nitric  acid  to 
the  part. 

In  this  absence  of  constitutional  symptoms  and  also  of  rapid  ex- 
tension, ulcerative  stomatitis  differs  from  cancrum  oris,  which  we 
have  presently  to  notice ;  as  far  as  the  ulceration  itself  is  concerned 
nothing  could  have  a  more  unhealthy  aspect  than  the  diseased 
surface,  though  it  is  devoid  of  the  livid  redness,  the  angry  tume- 
faction and  the  ashy  slough  of  the  latter  disease.  The  one,  however, 
is  a  purely  local  disease,  the  other  is  attended  by  the  severest  con- 
stitutional symptoms.  The  two  diseases  bear  a  close  analogy  with 
other  so  called  sporadic  and  epidemic  affections,  with  fatal  and  non- 
fatal  influenza  or  cholera.  They  thus  have  more  than  their  own 

1  The  disease  termed  pseudomembranous  stomatitis  appears  to  correspond  in  part 
to  this  form  and  in  part  to  that  known  as  follicular  stomatitis.  Ulcerative  stomatitis 
is  also  called  diphtheritic  stomatitis  and  cancrum  oris  by  Nieineyer  and  other  German 
authors  ;  but  since  both  terms  are  otherwise  interpreted  by  English  readers  it  appears 
unadvisable  to  accept  the  altered  nomenclature. 


32  ON    DISEASES    OF    THE    TONGUE    AND    MOUTH. 

share  of  interest,  and  have  a  bearing  upon  one  of  the  vexed  patholo- 
gical questions  of  the  day,  viz.,  the  relation  of  cryptogamic  organisms 
to  the  origin  and  extension  of  local  inflammation  and  the  causation 
of  febrile  conditions.  The  more  simple  form  of  the  disease  has  many 
points  in  favor  of  origination  in  some  local  cause,  such  as  fungus 
growth,1  while  the  more  malignant  type  is  also  closely  similar  in  its 
onset,  progress  and  result  to  severe  septicoemic  conditions,  which  are 
thought  by  many  to  be  associated  with  the  development  of  vegeta- 
ble organisms  in  the  blood  and  tissues.  No  positive  evidence,  how- 
ever, can  be  adduced  from  cases  of  ulcerative  stomatitis,  for  no 
adequate  examination  of  the  tissue  bordering  on  the  ulcerated  part 
can  be  made,  and  the  mere  scrapings  from  the  sore,  though  often 
containing  fungus- spores,  are  of  no  value  because  similar  results  may 
be  obtained  from  the  mouth  of  any  healthy  person. 

In  many  patients  suffering  from  early  phthisis  the  edges  of  the 
gums  become  red  and  slightly  swollen;  this  was  noticed  some  years 
ago  by  Dr.  Th.  Thompson,  and  we  find  a  similar  but  more  spongy 
condition  in  those  who  for  many  weeks  are  fed  upon  a  diet  destitute 
of  fruit  or  of  vegetables.  In  the  treatment  of  irritable  conditions  of 
the  stomach  and  other  forms  of  disease  the  necessity  of  some  vege- 
table diet  is  often  lost  sight  of,  and  the  general  health  of  the  patient 
suffers  in  consequence.  This  state  is,  in  fact,  the  incipient  stage  of 
the  spongy  and  granulating  gums  seen  in  true  scurvy,  a  state  which 
often  leads  to  hemorrhage,  and  is  one  of  very  great  diagnostic  value ; 
similar  hemorrhage2  occurs  in  the  less  severe  condition  of  spongy 
gums  from  mal-nutrition.  The  hemorrhage  in  purpura  haemorrha- 
gica  is  of  an  essentially  different  character.  Whilst  referring  to  the 
state  of  the  gums  we  may  mention  a  change  which  is  due  to  altera- 
tion in  the  gum,  a  deposit  in  it,  namely,  the  lead  line  in  chronic 
poisoning  by  that  metal;3  it  is  a  granular  deposit  in  the  gum  of  the 
sulphite  of  lead,  from  the  decomposition  of  the  lead  absorbed  into 
the  system  by  the  sulphuretted  hydrogen  from  decomposing  food. 
The  black  pigmental  patches  observed  on  the  lips,  gums,  and  tongue 
in  Addison's  disease  are,  on  the  contrary,  a  more  diffused  pigmental 
change  in  the  substance  of  the  mucous  membrane.  They  are,  how- 
ever, sometimes  present  without  any  disease  of  the  supra-renal  cap- 
sules.4 

Mercurial  stomatitis  hardly  needs  a  separate  description;  it  is  an 
ulcerative  form  of  disease  attended  by  profuse  salivation.  Regarded 
merely  as  an  ulcerative  disease  of  the  mouth  it  is  best  treated  by  the 
remedies  applicable  to  simple  cases,  and  chlorate  of  potash  is  all  that 
is  requisite,  both  given  internally  and  used  as  a  gargle.  For  profuse 

1  A  disease  which  seems   to  consist  in  a  derangement  of  the   alimentary  canal, 
accompanied  by  fever  and  the  presence  of  vesicles  on  the  mucous  membrane  of  the 
tongue  and  mouth,  which  rupture  and  leave  superficial  ulcerations,  appears  to  have 
been  sometimes  produced  by  the  consumption  of  the  milk  of  cows  suffering  from  the 
foot  and  mouth  disease. — '  Rep.  Med.  Officer  of  the  Privy  Council,'  1869,  Dr.  Thome. 

2  "  Hemorrhagic  iSudamina,"  described  by  Pye-Smith,  '  Virchow's  Archiv,'  vol.  i, 
p.  452. 

"  Dr.  Hilton  Fagge,  in  '  Med.-Chir.  Trans,,'  1876,  vol.  lix,  p.  327. 
«  'Path.  Trans.,'  1873,  p.  94. 


ON  DISEASES  OF  THE  TONGUE  AND  MOUTH.         33 

salivation,  however,  belladonna  has  recently  been  recommended. 
Heidenhain,1  in  some  experiments  on  the  influence  of  belladonna  on 
the  salivary  gland,  has  found  that  the  fibres  of  the  chorda  tympani 
which  act  upon  the  secreting  gland-cells  are  paralyzed  by  its  admin- 
istration, and  this  has  subsequently  been  corroborated  in  actual 
practice.2  Carbolic  acid  lotion  will  also  be  found  to  be  of  service  in 
checking  ulcerative  action.  Gentle  magnesian  purgatives  should  be 
given  to  remove  the  mercurial  from  the  intestinal  tract,  and  the 
health  should  be  invigorated  by  a  nourishing  diet  and  by  fresh  air. 

Still  more  severe  is  gangrenous  stomatitis,  or  cancrum  oris  ;  it  is 
one  of  the  most  terrible  forms  of  disease  ever  observed  in  young 
children.  It  occurs  more  especially  between  the  ages  of  two  and 
five ;  the  little  patient,  thin,  weak,  and  cachectic,  has  some  swelling 
of  the  gums  and  mouth;  on  examination  one  cheek  is  found  to  be 
especially  affected,  there  is  a  hard  and  diffused  swelling,  and  on  the 
inner  side  a  dark  ashy  spot  is  recognizable;  this  is  a  minute  slough, 
and  rapidly  spreads  in  depth  and  in  extent;  it  reaches  to  the  external 
surface,  and  the  cheek  becomes  perforated.  As  the  sloughing  spreads 
the  cheek  is  more  and  more  destroyed,  and  the  whole  cavity  of  the 
mouth  is  laid  open;  a  miserable  condition  is  thus  presented,  the 
alveoli  are  laid  bare  and  seen  from  without,  and  a  ghastly  spectacle 
is  witnessed ;  with  this  destruction  of  parts  there  is  offensive  smell 
and  breath,  there  is  much  constitutional  exhaustion,  and  fatal  bron- 
chitis or  pneumonia  supervenes.  Such  patients  are  also  liable  to  die 
from  pyaemia,  since  there  is  a  great  risk  in  all  diffuse  inflamma- 
tions about  the  face  of  plugging  of  the  facial  vein  (thrombosis),  and 
secondary  infection  of  the  lungs.  The  part  appears  to  die  from  the 
commencement.  Unless  the  disease  be  very  speedily  arrested  the 
most  disastrous  results  follow  either  in  the  destruction  of  the  face  or 
in  the  death  of  the  patient.  The  best  plan  of  treatment  is  to  destroy 
the  slough  by  strong  nitric  acid,  and  to  apply  carbolic  acid  lotion; 
to  use  a  stimulating  and  nourishing  diet,  port  wine  or  brandy,  milk, 
eggs,  and  strong  soup ;  and  as  to  medicine,  bark  or  quinine  with 
dilute  hydrochloric  acid  and  chlorate  of  potash  are  the  best  remedies 
to  employ. 

We  have  thus  several  forms  of  inflammation  of  the  mouth  of  dif- 
ferent degrees  of  severity,  simple  inflammation,  or  inflammation  with 
severe  and  phagedaenic  ulceration,  or  lastly  of  a  gangrenous  character. 

Inflammation  of  the  tongue  or  glossitis  is  also  a  disease  which  varies 
greatly  in  severity ;  sometimes  it  is  only  an  accompaniment  of  general 
stomatitis,  or  of  catarrhal  inflammation,  and  the  tongue  is  but  slightly 
swollen  and  injected,  but  at  other  times  the  whole  substance  is  in- 
volved. It  is  cedematous  and  so  much  swollen  that  it  protrudes 
beyond  the  teeth,  and  cannot  even  be  retained  between  the  lips; 
there  is  profuse  secretion  of  saliva,  the  respiration  is  obstructed,  and 
death  may  take  place  from  apnoea.  There  is  febrile  disturbance,  the 
pulse  is  compressible  and  dicrotic;  the  patient  is  scarcely  able  to 

1  '  Pfluger's  Archiv,'  vol.  xl ;  also  Lauder  Brunton,  '  Lond.  Med.  Rev.,'  i,  17. 

2  Ebstein,  'Berliner  Klinische  Wochenscrift,'  1873. 

3 


34  ON    DISEASES    OF    THE    TONGUE    AND    MOUTH. 

swallow,  and  there  is  dyspnoea  with  inability  to  lie  down  or  to  sleep 
from  the  interference  with  free  respiration ;  under  these  circumstances 
the  mind  becomes  depressed,  and  the  patient  forbodes  a  disastrous 
termination.1  Acute  glossitis  has  been  known  to  occur  in  association 
with  granular  kidneys.  A  man  was  admitted  into  Guy's  Hospital 
under  Mr.  Birkett's  care  in  1863  for  glossitis ;  the  tongue  filling  up, 
and  protruding  from  the  mouth.  There  was  no  apparent  danger  of 
suffocation,  but  the  symptoms  increased  during  the  night  and  he  was 
found  dead  in  the  morning.  The  post-mortem  showed  cystic  and 
granular  kidneys,  much  swelling  of  the  tongue,  and  oedema  also  of 
the  palate.  This  state  of  acute  glossitis  may  also  be  caused  by  irri- 
tant poisons,  such  as  mercury,  the  dust  of  ipecacuanha,  of  croton  oil 
seeds,  or  it  may  be  produced  by  catarrh  and  the  exposure  to  fog  and 
damp.  A  case  of  this"  kind  was  admitted  under  my  care  at  Guy's 
Hospital.  A  young  man  after  exposure  to  cold  was  seized  with 
symptoms  of  catarrh  and  inflammation  of  the  mouth ;  the  tongue 
became  swollen,  there  was  profuse  secretion  of  saliva,  and  the  respi- 
ration was  interfered  with  ;  the  tongue  never,  however,  became  in- 
ordinately enlarged,  and  although  for  two  or  three  days  the  patient 
was  unable  to  sleep,  the  disease  soon  subsided  without  any  untoward 
symptom.  This  might  be  regarded  as  catarrhal  glossitis. 

In  another  case  more  recently  a  youth  about  sixteen  years  of  age 
was  admitted  under  my  care  with  acute  inflammation  of  the  tongue; 
there  was  much  swelling,  and  an  incision  was  ordered  to  be  made ; 
the  distress  increased,  and  again  an  incision  was  made  on  the  other 
side ;  a  third  time  a  deeper  incision  opened  a  large  abscess  near  the 
base  of  the  tongue  and  extending  towards  the  left  tonsil.  The 
abscess  was  washed  out  with  Condy's  fluid,  and  there  was  speedy 
relief  to  the  severe  distress,  but  several  days  were  required  for  the 
closure  of  the  abscess.  The  patient  left  the  hospital  well. 

Glossitis,  although  at  first  severe  and  distressing  to  the  patient, 
generally  subsides  in  mild  cases  after  a  few  days,  and  the  tongue 
regains  its  normal  suppleness ;  in  other  cases  suppuration  follows 
and  an  abscess  is  formed,  or  chronic  thickening  of  the  organ  may 
supervene. 

In  the  treatment  of  this  disease  ice  may  be  applied  to  the  tongue ; 
it  is  refreshing  to  the  patient  and  relieves  the  hyperaemia  of  the  parts. 
Saline  medicines  may  be  administered,  such  as  the  nitrate  and  citrate 
of  potash  ;  the  bowels  should  be  freely  acted  on,  and  if  medicine  can- 
not be  swallowed  a  castor  oil  or  colocynth  enema  should  be  used.  If, 
however,  the  swelling  of  the  tongue  increase  to  such  an  extent  as  to 
interfere  with  respiration,  free  incisions  should  be  made  in  the  organ, 
and,  if  necessary,  even  tracheotomy  should  be  performed. 

Chronic  inflammation  of  the  tongue  is  a  very  troublesome  form  of 

1  A  case  of  suftglossitis  is  described  by  Mr.  Holthouse  in  the  '  Clinical  Society's 
Trans.,'  vol.  ii,  p.  140,  which  appears  to  be  a  less  severe  state  than  that  here  described 
as  acute  glossitis.  A  man  of  31  was  suddenly  attacked  by  swelling  of  the  tongue, 
which  formed  a  hard,  solid  lump,  filling  up  the  posterior  part  of  the  mouth  from  floor 
to  roof.  He  had  much  salivation  and  difficult  deglutition,  but  no  dyspnoea.  It  ap- 
peared to  be  a  solid  oedema  of  the  subglossal  region.  It  lasted  four  days,  and  appeared 
to  be  relieved  by  quinine,  but  not  by  incision. 


ON  DISEASES  OF  THE  TONGUE  AND  MOUTH.         35 

disease.  I  have  especially  seen  it  in  women  advanced  in  life ;  in 
many  cases  the  age  is  between  sixty  and  seventy.  There  is  general 
feebleness,  but  the  especial  complaint  is  of  the  tongue,  which  is 
swollen  and  red,  some  parts  being  of  a  more  deep  color  than  others ; 
the  movements  of  the  tongue  and  deglutition  are  painful,  and  there 
is  increase  in  the  quantity  of  the  saliva ;  the  health  is  not  otherwise 
much  disturbed.  In  some  instances  the  mucous  membrane  of  the 
nose  is  affected,  and  some  have  traced  the  disease  in  the  mouth  to 
irritation  commencing  in  the  nose.  Diseases  of  the  teeth  or  jaws 
may  set  up  the  mischief  in  the  mouth,  and  the  composition  of  the 
setting  of  false  teeth  may  be  a  source  of  irritation.  An  interesting 
paper  on  this  subject  appeared  in  the  '  Medical  Press  and  Circular'1 
by  the  late  Dr.  Woodman. 

The  appearance  of  the  tongue  in  these  cases  suggests  the  idea  of  a 
local  form  of  inflammation  resembling  eczema  of  the  skin.  In  the 
treatment  it  is  most  important  to  remove  every  source  of  irritation, 
but  treatment  is  very  unsatisfactory.  Demulcents  should  be  used 
such  as  mucilaginous  drinks,  with  borax  and  chlorate  of  potash  ; 
tonics  should  be  given,  such  as  quinine  and  steel,  and  they  are  best 
administered  as  pills ;  but  all  these  remedies  are  often  quite  unavail- 
ing, and  we  find  only  very  slight  relief  is  afforded.  The  most  sooth- 
ing combination  for  local  application  I  have  found  consists  of  small 
doses  of  carbonate  of  soda  with  hydrocyanic  acid  in  the  emulsion  of 
sweet  almonds.  I  have  often  thought  of  administering  small  doses 
of  arsenious  acid,  with  the  idea  of  the  eczematous  character  of  the 
disease.  Hypertrophy  of  the  papillae  of  the  tongue  is  often  found  to 
be  produced  by  some  prolonged  local  irritation,  as  a  roughened  tooth, 
etc.,  and  the  appearance  may  be  a  general  or  a  local  one  ;  in  the  latter 
case,  if  warty  in  character,  it  is  sometimes  with  great  difficulty  dis- 
tinguished from  epithelioma.  The  symptoms  are  pain  during  masti- 
cation and  deglutition,  and  in  some  cases,  to  use  a  patient's  expression, 
"an  aching  of  the  tongue  itself."  There  is,  however,  no  glandular 
enlargement,  the  disease  persists  for  a  long  period  without  spread- 
ing, and  there  is  less  tendency  to  degenerative  or  ulcerative  change. 

Another  very  important  condition  requiring  a  short  separate  con- 
sideration is  the  ulcerated  state  of  the  tongue  found  in  phthisis.  I 
am  not  now  alluding  to  the  merely  aphthous  state  observed  in  its 
later  stages,  but  to  a  condition  which  may  be  present  even  before 
the  disease  in  the  lung  is  of  sufficient  advancement  to  enable  it  to  be 
detected  by  the  stethoscope.  Two  cases  of  this  kind  have  lately 
been  under  my  colleagues  Mr.  Forster  and  Mr.  Bryant  at  Ohiy's  Hos- 
pital. In  the  one,  a  woman,  there  was  sufficient  chest  complication 
to  make  the  diagnosis  easy,  though  she  only  applied  for  treatment 
on  account  of  her  tongue  ;  there  was  no  evidence  of  syphilitic  poison. 
The  other,  a  man,  set,  50,  had  a  swollen  and  ulcerated  tongue,  in  one 
or  two  places  it  was  deeply  excavated,  in  others  fissured,  in  other 
parts  superficially  ulcerated  and  coated  with  lymph.  The  whole 

1  'Medical  Press  and  Circular,'  December  9,  1874. 


36  ON    DISEASES    OF    THE    TONGUE    AND    MOUTH. 

organ  thus  presented  a  swollen  and  livid  red  appearance,  dotted  over 
with  yellow  lymph  spots  quite  characteristic  of  the  disease  and  sug- 
gesting phthisis.  The  chest  was  examined  carefully  to  corroborate 
the  diagnosis,  and  with  the  result  of  only  finding  some  dulness  and 
doubtful  tubular  breathing  at  one  apex,  indicative  of  old  disease,  and 
it  seemed  as  if  in  this  instance  the  features  of  the  disease  had  failed 
lor  a  diagnosis.  The  patient,  however,  died  in  less  than  a  month 
with  extensively  distributed  and  recent  disease  of  the  lungs.1 

With  regard  to  syphilitic  affections  the  simple  forms  of  ulceration 
frequently  come  before  the  physician  generally  as  an  irregular  form 
of  ulceration,  serpiginous  and  superficial,  on  the  tongue,  tonsils,  and 
fauces.  Occasionally  we  meet  with  mucous  patches  and  gummata, 
which  may  be  mistaken  for  abscesses  or  subacute  glossitis.  In  chil- 
dren, also,  the  subjects  of  congenital  syphilis,  an  intractable  form  of 
ulceration  of  the  tonsil  is  occasionally  found.  It  would  be  difficult 
to  single  out  any  special  characteristic  as  attaching  to  a  syphilitic 
ulcer  on  the  tongue  or  fauces.  As  on  the  skin  it  has  a  tendency  to 
great  irregularity  of  border,  such  as  is  seen  in  few  other  instances  of 
ulceration,  and  this,  with  other  syphilitic  traces  elsewhere,  which 
will  in  most  cases  be  present,  must  suffice  for  the  diagnosis.  The 
fibroid  growth  in  the  tongue  in  syphilis  is  generally  easy  of  recogni- 
tion, and  also  the  irregularly  puckered  and  white  condition  of  the 
surface  due  to  a  similar  disease.  As  to  other  diseases,  Fairlie  Clarke2 
mentions  neuralgia  of  the  tongue  as  occurring  occasionally  and  being 
exceedingly  painful.  As  a  rule  this  affection  generally  affects  only 
one  side,  and  is  due  to  teeth  irritation  or  some  gastric  disturbance. 
Faradization,  and  even  excision  of  portions  of  the  nerve,  have  been 
recommended  for  its  relief. 

Spasm  of  the  tongue  is  also  described  by  Eomberg.3  It  is  said  to 
be  associated  with  hysteria,  neuralgia,  and  meningitis. 

Lastly,  Paget4  has  described  a  condition  of  ringworm  of  the  tongue, 
a  state  due  to  the  growth  of  a  fungus  in  curved  undulating  lines  on 
the  dorsum,  and  shortly  described  by  Dr.  Fairlie  Clarke.  M.  Maurice 
Raynaud5  has  also  described  patches  on  the  tongue  in  character 
exactly  resembling  those  of  tinea  tonsurans. 

It  is  not  necessary  for  me  to  enter  upon  the  consideration  of  such 
diseases  as  congenital  hypertrophy,  hydatid  diseases,  hypertrophy  of 
one  or  more  of  the  component  tissues  of  the  tongue,  of  fibroid 
growths,  or  of  cancer ;  these  are  all  strictly  surgical,  and  are  beyond 
the  limits  of  this  work. 

1  A  somewhat  similar  case  is  reported  by  M.  Trelat  in  the  '  Archives  Ge"nerales  de 
Med.,'  January,  1870. 

1  '  Diseases  of  the  Tongue.' 

3  '  Diseases  of  the  Nervous  System,'  Syd.  Soc.  Trans. 

4  It  is  thus  given  in  Sir  James's  own  words  : — "This  patient,  a  heal  thy  gentleman, 
had  observed  the  disease  more  than  a  year.    On  his  tongue  there  was  a  bare  purplish- 
pink  patch  over  nearly  half  the  right  side.     This  patch  was  all  bare,  i.  e.,  it  had  a 
very  thin  cuticle  and  no  fur  ;  but  it  was  intersected  by  two  curved  lines,  and  at  its 
posterior  boundary  was  a  white  ring.     The  curved  lines  were  undulating,  map-like, 
looking  as  formed  of  low  banks  of  heaped-up  cuticle."     Fairlie  Clarke,  '  Diseases  of 
the  Tongue,'  p.  88. 

«  'Archiv.  Ge'ne'rale's  de  Me"decine,'  1872. 


ON  DISEASES  OF  THE  TONGUE  AND  MOUTH.         37 

Inflammation  of  the  parotid  gland;  parotitis  ;  cynanche  parotidea. 

The  parotid  is  the  largest  of  the  salivary  glands,  and  consists,  not 
only  of  glandular  structure,  but  of  loose  binding  tissues.  1st.  The 
disease  occurs  as  a  simple  inflammation ;  2dly,  as  disease  of  a  spe- 
cific form,  the  mumps ;  and  3dly,  as  a  complication  of  typhus  and 
sometimes  of  other  fevers.1  The  symptoms  which  usher  'in  this  dis- 
ease are  febrile  disturbance,  a  sensation  of  stiffness  about  the  lower 
jaw,  quickly  followed  by  pain,  especially  during  movement,  and 
swelling :  the  pain  extends,  not  only  along  the  jaw,  but  into  the  ear 
and  over  the  head ;  the  swelling  is  generally  limited  to  one  side,  but 
sometimes  both  glands  are  affected  at  the  same  time ;  the  skin  is 
tense,  and  there  is  an  inflammatory  blush. 

The  submaxillary  and  lingual  glands  may  be  also  involved.  The 
febrile  symptoms  continue  for  three  or  four  days,  and  then  gradually 
subside.  In  rare  cases  suppuration  takes  place  in  the  cellular  tissue 
of  the  gland  ;  but  this  result  is  less  frequent  in  simple  parotitis  than 
in  cases  where  the  throat  has  been  affected  and  suppuration  has 
extended  in  the  course  of  the  Eustachian  tube,  or  has  burrowed 
amongst  the  muscles  of  the  back  of  the  neck. 

Specific  inflammation  of  the  parotid  or  mumps  is  a  contagious 
form  of  disease,  and  is  generally  observed  in  children.  The  symp- 
toms are  at  first  severe,  and  there  is  considerable  constitutional  dis- 
turbance ;  the  mammary  gland  in  girls,  or  the  testicle  in  males,  occa- 
sionally becomes  sympathetically  affected,  and  there  are  pain  and 
swelling  in  them :  in  other  cases  the  nervous  system  becomes  impli- 
cated in  a  marked  manner,  and  restlessness,  insomnia,  or  even  mani- 
acal symptoms  are  produced.  Again,  the  general  mucous  membrane 
of  the  digestive  tract  may  also  be  inflamed,  and  gastro-enteritic 
symptoms  result. 

As  a  complication  of  typhus  fever  the  enlargement  of  the  parotid 
gland  is  an  unfavorable  indication,  and  is  sometimes  associated  with 
sallowness  or  duskiness  of  the  countenance ;  this  condition  of  the 
parotid  occurs  in  in  the  second  week  of  typhus. 

With  the  exception  of  the  last  class  of  cases  the  prognosis  of  in- 
flammation of  the  parotid  of  a  simple  character  is  always  favorable. 
The  diagnosis  is  only  difficult  when  deep  seated  mischief  about  the 
pharynx  or  Eustachian  tube  has  taken  place,  and  when  the  tissues 
about  the  gland  are  only  secondarily  affected  ;  so  also  when  disease 
has  extended  from  the  mastoid  cells  or  from  the  teeth. 

The  treatment  consists  in  the  application  of  warmth,  in  the  use  of 
gentle  saline  aperients,  effervescing  draughts,  and  unstimulating  diet. 
Time  is  required,  for  the  disease  in  most  cases  runs  a  definite  course, 
and  cannot  be  obliterated  by  medical  treatment.  Convalescence  may, 
however,  be  promoted  by  the  use  of  tonics,  such  as  quinine  and  steel. 
If  there  be  excitement  of  the  nervous  system  then  bromide  of  po- 

1  Virchow  distinguishes  two  kinds  of  parotitis — idiopathic  and  symptomatic.  The 
former  being  what  is  popularly  termed  "  mumps, "only  occasionally  leads  to  abscess, 
but  not  infrequently  it  shows  a  disposition  to  metastasis.  The  symptomatic  form 
results  from  severe  disease,  as  typhus,  &c.  He  regards  both  as  a  catarrh  in  which 
the  gland-cells  take  part  in  the  diseased  process. 


38  ON    DISEASES    OP    THE    TOXGUE    AND    MOUTH. 

tassium,  with  chloral  hydrate  if  there  be  sleeplessness,  will  be  of 
service. 

The  tonsils  are  the  next  structures  that  we  have  to  notice ;  they 
are  situated  between  the  anterior  and  posterior  pillars  of  the  fauces 
and  immediately  beneath  the  soft  palate,  and  they  become  affected 
by  various  morbid  processes. 

The  tonsil  is  composed  of  several  tissues,  each  of  which  must  be 
taken  into  consideration  when  speaking  of  the  diseases  attaching  to 
it.  Externally,  i.  e.,  on  its  pharyngeal  aspect,  it  is  a  rounded  projec- 
tion which  is  covered  over  by  scaly  epithelium  and  has  many  depres- 
sions on  its  surface  into  which  this  scaly  lining  passes.  Thus  its 
surface  is  studded  with  small  pouches  or  follicles.  Enclosed  in  this 
external  membrane  are  numerous  lymphatic  follicles  arranged  in 
groups  and  with  fibrous  trabeculse,  bloodvessels  and  lymphatics  run- 
ning between  them.  These  various  parts  are  not  at  all  equally 
affected  in  tonsillar  disease;  in  one  there  is  affection  of  the  epithelial 
surface,  in  another  of  the  whole  substance,  and  lastly  the  interstitial 
stroma  is  involved.  In  each  form,  however,  all  the  component  struc- 
tures of  the  glands  participate,  although  the  structural  change  is 
predominant  in  one. 

They  may  be  classified  in  the  following  manner: — 

Catarrhal  inflammations  <  /™        •' 

|  Chronic. 

i  (  Acute  =  Quinsy. 

Parenchymatous  <  n,        •        TT     J          , 

J  (  (Jhronic  =  Hypertrophy. 

1.  Acute  catarrhal  inflammations   are    characterized   by  general 
swelling  of  the  mucous   membrane  with   injection  and  excess  of 
mucus,  sometimes  of  glairy,  sometimes  of  an  inspissated  character. 

To  this  group  belongs  acute  oedema,  generally  an  extension  of  dis- 
ease from  the  soft  palate  or  the  mouth. 

Erysipelatous  inflammation,  acute  catarrh,  diphtheria. 

2.  Chronic  catarrhal  inflammations,  attended  by  more  or  less  thick- 
ening of  the  mucous  surface,  although  not  of  the  whole  gland,  and 
by  plugging  of  the  glandular  crypts  with  effete  epithelial  products. 

3.  Acute  parenchymatous  inflammation,  where  the  whole  substance 
of  the  gland  is  swollen  and  may  rapidly  suppurate — Quinsy. 

4.  Chronic  parenchymatous  inflammation  is  a  disease  which  is  said 
to  be  productive  of  true  hypertrophy  of  the  gland,  but  it  is  more 
especially  dependent  upon  fibrinous  overgrowth  of  the  interglandular 
trabeculae,  with  enlargement  of  the  vessels.1     The  whole  gland  is 
enlarged  and  more  solid  than  normal.    This  state  is  commonly  known 
as  chronic  enlargement  of  the  tonsil. 

In  addition  to  these  more  common  forms  of  disease  the  tonsils  are 
not  uncommonly  subject  to  ulceration  similar  to  that  seen  in  other 
parts  of  the  mouth  in  ulcerative  and  syphilitic  stomatitis,  and  they 
are  occasionally  the  seat  of  severe  forms  of  ulceration  and  sloughing, 

1  :i  Microscopic  Examination  of  an  Enlarged  Tonsil,"  'Path.  Soc.  Trans.,'  vol.  xix, 
p.  211,  showing  it  to  be  a  true  hypertrophy  ;  the  Malpighian  corpuscles  were  closely 
packed,  with  very  little  stroma.  Mr.  W.  J.  Smith. 


ON  DISEASES  OF  THE  TONGUE  AND  MOUTH.         39 

which  are  sometimes  called  phlegmonous  inflammations,  sometimes 
diphtheritic,  but  which  would  appear  to  occur  under  a  variety  of 
morbid  states.  This  state  is  sometimes  seen  in  severe  forms  of  pneu- 
monia, in  typhoid  fever,  in  dysentery;  and  it  is  of  especial  interest 
to  note  that  these  severe  affections  of  the  fauces  are  to  be  found 
more  especially  in  association  with  sloughy  or  phlegmonous  states  of 
intestine.1  Besides  these  we  also  find  strumous,  syphilitic,  and  can- 
cerous diseases. 

(1.)  In  acute  catarrh  the  tonsils  and  the  mucous  membrane  become 
oedematous  and  congested;  the  color  of  the  mucous  membrane  is 
changed,  it  is  reddened,  and  the  line  of  demarcation  is  sometimes  as 
denned  as  with  erysipelas  affecting  the  skin,  the  swelling  may  be  so 
great  that  the  soft  palate  and  the  uvula  are  twice  their  natural  size, 
and  the  parts  almost  corne  in  contact  the  one  with  the  other;  in 
erysipelatous  inflammation  the  oedema  is  very  marked  and  the  color 
is  dusky;  if,  however,  the  oedema  is  passive  and  chronic  the  color  is 
less  dark.  The  extent  of  the  elongation  of  the  uvula  and  its  shape 
are  very  different  in  the  cases  of  passive  oadema;  sometimes  the 
extremity  of  the  uvula  is  rounded  and  swollen,  at  other  times  elon- 
gated, pointed,  and  a  quarter  to  half  an  inch  beyond  its  proper  pro- 
portions. It  will  then  reach  the  tongue  or  the  posterior  portion  of 
the  pharynx  and  produce  violent  dry  retching  or  cough. 

Sometimes  in  acute  inflammation  of  the  tonsil  the  secretion  is 
altered  and  thin  white  patches  are  observed  on  the  gland,  resembling 
diphtheritic  exudation,  or  there  is  a  raised  portion  of  the  mucous 
membrane,  whitish  in  color,  which  leaves  a  raised  irregular  edge 
and  is  often  mistaken  for  an  ulcer ;  this  condition  is  an  acute  one, 
and  subsides  after  three  or  four  days,  but  it  is  not  true  diphtheria. 
(2.)  If  the  disease  be  less  acute,  the  secretion  is  altered  and  a  white 
secretion  appears  in  the  crypts  of  the  gland,  as  if  the  extremities  of 
the  follicular  ducts  were  distended ;  this  condition  also  is  often  mis- 
taken for  one  of  ulceration.  With  this  follicular  inflammation  of  the 
tonsil  the  mucous  membrane  of  the  pharynx  is  also  affected ;  it  be- 
comes congested,  the  surface  appears  irregular  and  granular,  the 
veins  are  enlarged  and  sometimes  lead  to  hemorrhage.  It  is  this 
condition  that  is  sometimes  called  clergyman's  sore  throat,  and  it  is 
a  state  of  chronic  congestion  with  follicular  inflammation.  When 
the  glands  behind  the  pharynx  become  enlarged,  they  may  push  for- 
ward the  mucous  membrane  on  one  or  other  side,  so  that  the  canal 
appears  narrowed  and  one-sided.  (3.)  If  the  whole  gland  is  inflamed 
and  the  parenchyma  affected — acute  tonsillitis — there  is  general 
swelling  of  the  gland ;  the  anterior  fauces  are  greatly  narrowed,  and 
the  tonsils  nearly  meet.  If  suppuration  ensue,  the  swelling  is  still 
greater ;  there  is  softening  of  the  part,  and  fluctuation  can  be  felt, 
unless  the  affection  be  confined  to  the  posterior  region ;  as  the  acute 
disease  subsides  it  oftens  leaves  chronic  enlargement  of  the  gland, 

1  In  reference  to  cases  of  this  kind  vide  '  Path.  Soc.  Trans.,'  vol.  xxvi,  p.  84, 
"Acute  Enteritis,"  by  Dr.  Goodhart ,  vol.  xix,  p.  217.  "Sloughing  of  Tonsils,"  by 
Dr.  J.  Osier  Ward;  vol.  xi,  p.  106,  "Calculus  from  Tonsil,"  by  Dr.  Silt,  for  Dr. 
Baker. 


40  ON    DISEASES    OF    THE    TONGUE    AND    MOUTH. 

(4),  which  is  increased  by  each  subsequent  attack,  especially  in 
weakly  and  strumous  children. 

The  symptoms  produced  will  vary  according  to  the  severity  of  the 
attack ;  in  simple  oedema,  the  febrile  disturbance  is  often  severe,  the 
temperature  may  suddenly  become  high,  from  103°  to  105°,  there  is 
much  irritation,  dysphagia,  pain  towards  the  ear  on  swallowing,  the 
tongue  is  furred  and  generally  the  whole  mucous  membrane  of  the 
mouth  is  affected.  If  the  uvula  be  elongated,  then  there  is  dry 
cough  and  vomiting,  and  these  symptoms  are  often  especially  observa- 
ble in  the  morning  ;  patients  are  sometimes  supposed  to  have  severe 
bronchitis,  whereas  the  mischief  is  simply  in  the  throat. 

In  erysipelatous  inflammation,  in  which  there  is  duskiness  with 
oedema,  there  is  great  prostration  with  the  febrile  symptoms  and 
more  distress,  the  attack  comes  on  suddenly,  and  if  it  extend  to  the 
epiglottis  and  glosso-epiglottidean  folds  of  mucous  membrane  these 
parts  become  cedematous  and  dyspnoea  of  a  dangerous  character  is 
produced.  In  follicular  inflammation  the  symptoms  are  more 
chronic;  there  is  hoarseness,  cough,  and  much  distress,  but  without 
febrile  symptoms.  In  acute  inflammation  of  the  tonsils,  there  is  also 
much  febrile  disturbance,  with  pain  and  distress,  deglutition  is  difficult 
and  very  painful,  and  food  is  sometimes  rejected  by  the  nares,  or  the 
patient  is  unable  even  to  swallow  saliva ;  he  cannot  sleep,  for  the 
disease  in  the  throat  interferes  with  respiration ;  the  tongue  is  much 
furred,  it  is  swollen,  and  in  fact  the  whole  mucous  membrane  of  the 
mouth  is  involved ;  the  breath  becomes  offensive,  and  the  gums 
covered  with  concretion ;  this  condition  may  gradually  subside,  or 
with  increasing  distress  rigor  comes  on,  and  after  a  longer  or  shorter 
interval  the  pus  which  has  formed  finds  a  free  vent  and  there  is 
sudden  relief  to  the  urgent  symptoms ;  in  some  cases  a  fatal  termina- 
tion suddenly  supervenes  from  suffocation  or  from  exhaustion  ;  sup- 
puration, however,  in  some  cases  reaches  to  the  loose  cellular  tissue 
external  to  the  tonsil,  and  it  may  burrow  among  the  muscles  of  the 
neck ;  ulceration  also  ensues,  and  there  is  then  an  excavation  on  the 
surface  of  the  tonsil  sometimes  extending  into  its  substance. 

In  syphilitic  and  in  strumous  subjects  this  ulceration  has  a  peculiar 
and  characteristic  appearance,  in  the  former  having  a  somewhat 
circular  margin,  serpiginous  in  outline,  in  the  latter  with  irregularly 
raised  edges  and  extending  in  both  cases  to  the  soft  palate,  leading 
to  its  destruction  and  often  to  perforation.  In  syphilitic  ulceration 
of  the  tonsil  the  disease  sometimes  extends  to  the  soft  palate,  and  a 
circular  red  line  of  inflammation  may  be  seen  across  the  soft  palate 
after  ulceration  has  ceased,  the  disease  spreading  in  the  same  manner 
as  psoriasis  of  the  skin. 

In  chronic  hypertrophy  of  the  tonsil  the  glands  present  an  irregular 
and  pitted  appearance ;  the  enlarged  glands,  when  increased  by  a 
sudden  accession  of  acute  disease,  almost  meet,  and  all  the  symptoms 
of  the  acute  disease  may  be  produced.  Very  slight  causes  suffice  to 
produce  this  aggravation  of  symptoms  when  the  tonsils  are  chroni- 
cally affected,  and  what  is  often  of  great  annoyance  to  the  patient 
the  Eustachian  tubes  are  pressed  upon,  and  the  sense  of  hearing  is 


ON.  DISEASES    OF    THE    TONGUE    AND    MOUTH.  41 

interfered  with.  In  many  instances,  as  the  acute  disease  subsides, 
the  partial  and  temporary  obstruction  of  the  tube  causes  some  deaf- 
ness, but  in  chronic  hypertrophy  the  deafness  is  more  permanent. 
Another  consideration  must  be  borne  in  mind,  namely,  that  persistent 
enlargement  of  the  tonsil  interferes  with  the  voice,  and  with  the 
entrance  of  air  into  the  lungs ;  hence  in  children  it  is  not  unlikely  to 
interfere  with  growth  and  may  lead  to  imperfect  nutrition. 

In  investigating  the  causes  of  these  inflammatory  diseases  of  the 
tonsil  we  find  that  strumous  subjects  manifest  greater  liability  to 
them,  and  also  in  such  patients  a  recurrence  of  disease  is  very  apt  to 
take  place.  Cold  is  the  most  common  exciting  cause,  but  there  is  a 
greater  tendency  to  disease  of  the  tonsil,  especially  of  an  acute  kind, 
when  the  nervous  system  is  exhausted  and  nutrition  is  impaired. 

There  is  much  difference  of  opinion  amongst  medical  practitioners 
as  to  the  best  mode  of  treating  acute  disease  of  the  tonsils.  The 
application  of  warmth  to  the  throat  in  the  form  of  cotton  wool 
externally,  or  a  hot  linseed  poultice,  or  the  "  wet  pack"  in  the  form 
of  a  cloth  wrung  out  of  water,  will  often  suffice  to  relieve  the  disease 
without  any  other  treatment.  Stimulating  liniments  may  be  used, 
such  as  the  compound  camphor  liniment  applied  on  lint  or  rubbed 
in,  or  a  mustard  poultice  may  be  used.1  In  the  mouth  itself  ice  is 
often  very  grateful,  but  as  a  rule  warmth  is  more  pleasant.  Lunar 
caustic  or  nitrate  of  silver  may  be  useful,  if  the  disease  is  circum- 
scribed ;  but  unfortunately,  in  most  instances,  the  mischief  is  more 
extensive  and  the  relief  thus  afforded  is  only  temporary,  and  in  some 
cases  it  aggravates  the  disease  and  increases  ulcerative  changes.  It 
is  better  to  use  glycerine  of  tannin  alone,  or  diluted  with  water  as  a 
gargle,  or  as  a  vapor  with  a  spray  apparatus  ;  solution  of  chlorate  of 
potash  or  of  borax,  may  also  be  used,  and  if  there  be  any  tendency 
to  ulceration,  a  dilute  solution  of  carbolic  acid,  gr.  iv  to  3j,  is  a  good 
remedy  for  vaporization.  If  there  be  much  febrile  excitement  saline 
effervescing  medicines  may  be  given,  or  the  acetate  of  ammonia,  or 
dilute  hydrochloric  acid  with  chlorate  of  potash ;  if  there  be  weak- 
ness, a  frequent  and  irritable  or  compressible  pulse,  then  the  fluid 
extract  of  cinchona  bark  or  quinine  should  be  used.  In  nearly  all 
these  cases  it  is  very  important  to  sustain  the  patient  by  good  nour- 
ishment, such  as  milk,  eggs,  good  soup,  and  wine  or  ardent  spirits 
may  be  required.  The  prostration  of  strength  is  often  very  great, 
and  the  stimulant  effect  of  alcohol  is  of  great  service.  The  applica- 
tion of  tincture  of  iron  is  a  favorite  remedy  with  some  physicians, 
especially  if  the  disease  be  of  a  diphtheritic  character,  but  more 
soothing  remedies  are  preferable. 

In  chronic  disease  of  the  tonsils  with  hypertrophy  the  application 
of  caustic  tends  to  increase  the  flow  of  blood  to  the  part,  and  in  this 
manner  augments  the  disease ;  the  employment  of  solution  of  iodine 
is  objectionable  for  a  similar  reason ;  but  the  long-continued  appli- 

1  Dr.  S.  H.  Roberts  strongly  recommends  the  use  of  turpentine  externally  in  ton- 
sillitis, '  London  Med.  Record,'  vol.  i,  p.  395,  and  Dr.  Handfield  Jones  the  internal  use 
of  belladonna  '  Lancet,'  1871,  vol.  i,  p.  12. 


42  ON    DISEASES    OF    THE    TONGUE    AND    MOUTH. 

cation  of  nitrate  of  silver  is  still  more  objectionable,  for  it  may  be- 
come absorbed  and  produce  discoloration  of  the  skin.  This  would 
scarcely  be  regarded  as  possible,  unless  it  had  really  occurred.  A 
lady,  whom  I  saw  in  consultation  for  severe  colic,  was  found  to  have 
a  peculiar  indigo  discoloration  of  the  skin,  and  upon  inquiry  I  learned 
that  a  strong  solution  of  nitrate  of  silver  had  at  one  time  been  pre- 
scribed for  enlarged  tonsils  ;  this  solution  had  been  zealously  applied 
by  the  patient  and  her  nurse  for  a  period  of  two  years,  and  with  the 
effect  of  producing  discoloration  of  the  skin.  The  constant  employ- 
ment of  tannin,  either  dissolved  in  glycerine  and  used  with  a  camel- 
hair  pencil,  or  as  a  gargle,  or  with  a  spray  apparatus,  is  generally 
sufficient  to  lessen  the  size  of  the  glands.  For  a  like  purpose  also  a 
strong  solution  of  alum  may  be  used.  A  residence  at  the  sea-side 
or  in  dry  and  bracing  air,  nourishing  diet,  the  administration  of  cod- 
liver  oil  with  quinine  and  steel,  will  help  to  relieve  the  mal-nutrition 
connected  with  hypertrophy  of  the  tonsils,  and  to  lessen  the  growth 
of  the  glands  themselves.  In  other  cases  iodide  of  potassium  may 
be  given  with  iodine  or  the  iodide  of  iron,  and  iodine  may  be  painted 
on  the  skin.  It  is,  however,  well  not  to  employ  iodine  in  too  con- 
centrated a  form,  for  on  a  delicate  cutaneous  surface  it  produces 
much  irritation,  pain,  and  even  vesication ;  the  iodine  may  also  be 
used  by  inhalation.  Excision  of  the  tonsil  should  only  be  practised 
after  astringents  and  general  remedies  have  been  fully  employed ; 
but  in  young  subjects  it  is  especially  important  not  to  allow  these 
hypertrophied  glands  to  remain,  for  the  reasons  already  stated. 

The  hasty  removal  of  the  uvula,  however,  for -prolongation  and 
relaxation  is  very  much  to  be  deprecated ;  other  measures  may 
suffice,  and  its  excision  may  interfere  with  the  process  of  swallowing 
and  with  the  voice. 

In  oedema  of  the  tonsils  and  soft  palate  the  inhalation  of  soothing 
remedies  is  grateful  to  the  patient,  and  even  simple  steam  is  of  much 
benefit.  Astringents  may  be  similarly  employed  with  advantage, 
but  if  necessary  the  parts  should  be  scarified  or  incisions  made,  and 
this  is  the  more  necessary  when  the  cedema  extends  to  the  epiglottis 
and  glosso-epiglottidean  folds — cases  in  which  fatal  dyspnoea  some- 
times supervenes.  Such  cases  require  to  be  watched  very  carefully, 
for  after  sudden  excitement  perfect  freedom  of  respiration  may  give 
place  to  irregularity  of  breathing  and  to  urgent  dyspnoea,  and  the 
immediate  performance  of  tracheotomy  may  become  necessary  for 
the  preservation  of  life. 

If  the  cedema  be  associated  with  asthenic  or  erysipelatous  inflam- 
mation stimulants,  with  good  nourishment,  are  of  great  value.  Beef 
tea,  with  port  wine  or  champagne,  should  be  given  frequently ;  and 
astringents,  with  the  tincture  of  iron,  are  often  of  great  use  as  local 
applications.  As  regards  other  forms  of  medicine,  perhaps  bark, 
with  hydrochloric  acid,  is  productive  of  the  most  benefit.  When 
abscess  in  the  tonsil  is  present,  the  sooner  it  is  opened  the  better ;  if 
it  be  left,  the  dyspnoea  and  distress  increase,  and  the  local  mischief 
becomes  more  extensive  by  burrowing  among  the  loose  tissue  of  the 


ON    DISEASES    OF    THE    TOXGUE    AND    MOUTH.  43 

posterior  pillars  of  the  fauces.    An  abscess  protruding  into  the  fauces 
may  sometimes  be  opened  by  the  pressure  of  a  sharp  finger  nail. 

Cancerous  disease  of  the  tonsil  is  a  rare  form  of  disease,  and  is 
associated  with  enlargement  of  the  cervical  glands.  In  an  obscure 
case  of  this  kind  that  I  witnessed  some  years  ago,  nearly  every  fort- 
night or  three  weeks  swelling  of  the  neck  and  extreme  dysphagia 
came  on ;  the  cause  was  not  apparent,  but  it  was  found  after  death 
that  cancerous  disease  of  the  glands  had  exerted  pressure  on  the 
pneumogastric  nerve,  and  thereby  caused  the  dysphagia  and  other 
symptoms  of  disease.1 

Paralysis  of  the  soft  palate  must  also  be  mentioned  in  connection 
with  diseases  of  the  tonsils  and  adjoining  parts.  In  paralysis  from 
diseases  of  the  brain,  ordinary  apoplexy  with  hemiplegia,  the  di- 
minished power  of  the  tongue  and  muscles  of  deglutition  leads  to 
marked  dysphagia ;  sometimes  also  local  growth  of  a  syphilitic  or 
cancerous  character  exerts  pressure  on  the  hypoglossal  and  other 
nerves,  and  leads  to  diminished  power;  this  is  especially  observed  in 
that  interesting  class  of  cases  designated  labio-glosso-laryngeal  paraly- 
sis. The  spinal  accessory  nerve  is  probably  in  these  instances  impli- 
cated, the  muscles  of  the  face  are  weakened,  so  also  the  tongue,  but 
it  is  especially  in  the  soft  palate  and  in  the  muscles  of  the  pharynx 
that  the  loss  of  power  is  observed  ;  the  soft  palate  remains  powerless 
and  flaccid,  and  sensibility  is  lost.  The  attempt  to  swallow  may  be 
followed  by  the  passage  of  food  into  the  larynx,  and  in  a  case  of  this 
kind  under  my  care  in  the  clinical  ward  of  Guy's  in  187-4,  recorded 
in  the  '  Guy's  Reports,'  directions  had  been  given  to  feed  the  patient 
by  the  stomach-pump,  but  in  the  attempt  to  swallow  milk  a  portion 
passed  into  the  larynx  and  greatly  hastened  a  fatal  termination. 
Loss  of  power  of  the  soft  palate  is  also  observed  to  follow  diphtheria. 
These  latter  cases  slowly  recover,  so  also  where  the  weakness  is 
consequent  upon  the  full  use  of  bromide  of  potassium  ;  such  patients 
complain  of  inability  to  swallow,  with  weakness  and  mental  inertia. 
The  voice  is  altered,  especially  so  where  the  tongue  is  affected,  as  in 
cases  of  labio-glossal  laryngeal  disease. 

The  treatment  in  these  maladies  necessarily  varies  according  to 
the  nature  of  the  case,  but  faradization  is  often  of  great  value  in 
strengthening  the  muscles  of  the  soft  palate.  The  semi -paralyzed 
condition  of  the  palate  found  after  the  free  use  of  bromide  of  potas- 
sium soon  disappears  with  a  cessation  of  the  remedy.  We  have 
already  referred  to  a  similar  condition  of  atrophy  of  the  tongue  de- 
pendent upon  disease  of  its  nerves  or  of  the  central  nervous  centres 
(see  page  26).  In  progressive  muscular  atrophy  the  muscles  of  the 
tongue  share  in  the  general  disease,8  and  they  may  at  times  be  found 

1  A  valuable  collection  of  oases  of  primary  disease  of  the  tonsils  is  to  be  found  in  a 
paper  by  Mr.  Poland,  "On  Cancer  of  the  Tonsil  Glands,"  '  Medico-Chir.  Review,' 
1872,  p.  477.     Three  cases  of  cancerous  disease  of  the  tonsil  have  recently  occurred 
in  Guy's  Hospital,  and  for  a  very  interesting  case  with  cancer  of  the  spleen  and  lym- 
phatic glands  ses  '  Path.  Soc.  Trans.,'  vol.  xx,  p.  369,  by  Dr.  Moxon. 

2  'Archives  Generates  de  Medeoine,'  series  5,  vol.  i,  p.  571,  Cruveilhier. 


44  ON    DISEASES    OF    THE    TONGUE    AND    MOUTH. 

wasted  on  one  side  or  the  other  in  consequence  of  disease  in  the 
brain  or  at  the  origin  of  nerves. 

Such,  unhappily,  do  not  admit  of  much  treatment,  but  a  case  of 
Sir  James  Paget's,  already  referred  to,  shows  that  unilateral  wasting 
of  the  tongue  is  quite  remediable  should  it  happen  that  the  feause 
which  produces  it  can  be  removed.1 

1  For  other  cases  see  Hughlings  Jackson,  '  Lancet,'  1872,  vol.  ii,  p.  770  ;  Buzzard, 
'  Clin.  Soc.  Trans.,'  vol.  v,  p.  146;  "Case  of  Unilateral  Face  Atrophy,  dating  from 
an  attack  of  Chorea." 


45 


CHAPTER   III. 

ON  DISEASES  OF  THE  PHARYNX. 

THE  pharynx  is  continuous  by  the  fauces  with  the  mouth,  by  the 
posterior  nares  with  the  cavities  of  the  nose,  by  the  Eustachian  tubes 
with  the  ears,  by  the  superior  opening  of  the  larynx  with  the  respi- 
ratory organs,  and  by  the  commencement  of  the  oesophagus  with 
the  rest  of  the  alimentary  tract;  and  disease  of  any  of  these  con- 
tiguous parts  may  interfere  with  healthy  pharyngeal  action.  The 
mucous  membrane  of  the  pharynx  is  loosely  connected  with  the 
muscular  coat,  and  important  vessels,  nerves,  and  numerous  glands 
are  placed  on  the  external  aspect.  The  part  is  richly  supplied  with 
nerves,  from  the  pneumogastric,  the  glosso-pharyngeal  and  spinal 
accessory  nerves,  and  this  abundant  supply  has  an  important  bearing 
upon  some  pathological  conditions. 

Spasmodic  irritation. — Any  one  who  has  repeatedly  examined  the 
pharynx  is  well  acquainted  with  the  varying  sensibility  of  the  part, 
and  that  great  irritability  may  be  consistent  with  ordinary  health. 
The  most  intense  excitability  with  true  spasm  of  the  pharynx  is 
observed  in  hydrophobia.  Cases  of  this  kind  are  occasionally  seen, 
and  I  have  witnessed  three  instances,  two  in  young  men,  and  a  third 
in  a  little  girl.  In  the  first  case,  some  years  ago,  the  pharynx  pre- 
sented a  very  peculiar  appearance  on  inspection;  its  cavity  appeared 
more  than  twice  its  natural  size;  the  constrictor  muscles  were  re- 
tracted to  the  utmost,  and  the  fauces  were  exceedingly  large  from 
the  rigid  contraction  of  the  soft  palate;  the  spasmodic  condition  of 
the  muscles  rendered  every  part  of  the  pharynx  as  dilated  as  possible, 
whilst  from  similar  muscular  spasm  the  oesophagus  was  contracted. 
The  mucous  membrane  of  these  parts  was  injected  and  covered  with 
tenacious  mucus.  There  was  great  congestion  of  the  membranes  of 
the  brain  and  spinal  cord,  and  the  lungs  were  in  a  similar  state  of 
engorgement.  The  other  viscera  were  healthy,  but  there  was  em- 
physema of  the  cellular  tissue  of  the  neck.  The  symptoms  during 
life  indicated  extreme  irritability  of  the  nerves  supplying  the  pha- 
rynx, as  indeed,  of  all  the  branches  of  the  fifth  and  pneumogastric 
nerves. 

Inflammatory  diseases  of  the  pharynx  may  be  of  an  an  acute  or 
chronic  catarrhal  character,  or  the  inflammation  may  be  follicular, 
membranous,  or  phleymonous. 

The  catarrhal  states  scarcely  require  a  separate  description,  for  the 
mucous  membrane  is  continuous  with  the  tonsils  and  palate,  and  dis- 
ease extends  by  continuity  of  tissue.  This  is  also  the  case  with  diph- 
theritic inflammations,  and  also  in  the  exanthems,  as  scarlet  fever 
and  smallpox,  for  in  the  former  the  mischief  extends  into  the  pharynx, 


46  ON    DISEASES    OF    THE    PHARYNX. 

and  in  the  latter  pustules  have  been  observed  on  the  mucous  mem- 
brane of  the  fauces.  In  cedematous  and  erysipelatous  states  the 
tonsils,  palate,  and  pharynx  are  generally  affected.  In  catarrhal  in- 
flammation of  the  throat  the  mucous  membrane  is  red,  injected,  and 
swollen,  and  dysphagia  is  a  common  symptom ;  the  movement  of  the 
parts  produces  pain  in  the  direction  of  the  Eustachian  tubes,  and  de- 
glutition is  difficult. 

Chronic  catarrh  is  characterized  by  thickening  of  the  mucous  mem- 
brane, with  redness  and  slight  hoarseness ;  there  is  occasional  irrita- 
tion, which  is  relieved  by  the  expectoration  of  a  small  quantity  of 
mucus.  This  troublesome  affection  is  usually  described  by  the  pa- 
tient as  a  relaxed  throat,  and  it  is  closely  associated  with  foUicular 
inflammation,  with  which  many  of  the  symptoms  are  identical.  This 
is  a  less  severe  condition,  but  is  even  more  chronic;  the  mucous 
membrane  is  red  and  granular ;  the  veins  are  enlarged  and  varicose, 
the  adjoining  part  being  in  a  similar  state ;  irritable  cough,  hoarse- 
ness, and  dysphagia  are  induced.  If  with  these  symptoms  the  uvula 
is  relaxed,  vomiting,  especially  in  the  morning,  is  easily  induced. 
Over-speaking,  as  with  clergymen,  may  be  the  cause  of  this  follicular 
disease,  and  it  is  greatly  relieved  by  astringents  used  as  a  gargle,  or 
with  a  spray  apparatus,  as  alum,  tannin,  krameria;  and  sometimes 
by  stimulants,  such  as  capsicum,  guaiacum,  &c.  Tobacco  produces 
a  relaxed  condition  of  the  mucous  membrane  and  cough  is  a  common 
symptom  of  this  state.  The  best  remedy  is  to  give  up  the  exciting 
cause.  A  somewhat  similar,  if  not  identical  disease,  is  sometimes 
found  in  delicate  patients  of  a  strumous  tendency  or  with  chronic 
chest  disease.  It  shows  itself  in  such  persons  chiefly  by  an  excess  of 
viscid  mucus,  slightly  offensive,  about  the  posterior  nares  and  fauces, 
and  which  is  most  troublesome  in  the  morning.  The  efforts  at  clear- 
ing the  throat  under  such  circumstances  are  often  productive  of 
vomiting.  The  posterior  aspect  of  the  soft  palate  and  posterior  nares 
appear  to  be  equally  implicated  with  the  pharynx. 

Membranous  inflammation  of  the  pharynx  occurs  in  the  form  of 
croupous  or  of  diphtheritic  disease,  and  although  in  true  croup  the 
larynx  is  first  affected,  the  disease  may  extend  to  the  pharynx,  whilst 
in,  diphtheria,  in  which  the  pharynx  is  first  attacked,  the  mischief 
often  reaches  the  larynx  ;  still  we  regard  the  diseases  as  essentially 
distinct.  This  opinion  is,  however,  controverted  by  eminent  physi- 
cians, who  maintain  that  the  diseases  are  identical.  The  pathological 
character,  as  well  as  the  clinical  history,  is  different  in  the  two  dis- 
eases. In  croup  we  have  a  false  membrane  consisting  of  epithelial 
cells  and  inflammatory  product,  based  upon  a  congested  membrane ; 
in  diphtheria  the  membrane  is  also  composed  of  cellular  elements 
and  fibrinous  material,  exudatory  in  character,  and  the  result  of  in- 
flammatory change,  but  the  morbid  effusion  is  more  adherent  to  the 
structures  beneath,  and  the  subjacent  tissues  are  often  sloughing. 
Some  also  assert  that,  the  diphtheritic  membrane  is  fungoid  in  char- 
acter. In  the  fauces  and  tonsils  the  membrane  has  a  yellowish  color, 
it  is  tough,  and  is  adherent  to  the  surface  beneath,  and  its  separation 
leads  to  abrasion  and  to  bleeding.  The  croupous  membrane  in  the 


ON    DISEASES    OF    THE    PHAKYNX.  47 

larynx  is  less  consistent  and  less  adherent  to  the  tissues  beneath.  It 
is  not,  however,  that  every  membranous  exudation  in  the  fauces  and 
pharynx  is  diphtheria ;  on  the  contrary,  many  acute  diseases  already 
described  have  this  character,  and  in  general  exhaustion  of  the  system 
the  throat  becomes  injected,  granular,  and  may  have  an  inflammatory 
exudation  upon  it.  In  true  diphtheria  there  is,  then,  greater  ten- 
dency to  slough,  there  is  general  prostration  of  strength,  the  urine 
becomes  albuminous,  and  there  is  a  liability  to  subsequent  paralysis. 
In  croup  there  may  be  slight  albumen  in  the  urine  from  inflamma- 
tory congestion,  but  this  is  very  different  from  the  albuminuria  in 
diphtheria. 

As  to  the  general  symptoms,  there  is  febrile  excitement,  sudden 
elevation  of  temperature,  uneasiness  in  the  throat,  difficulty  in 
shallowing,  and  great  prostration  of  strength  ;  if  the  disease  extends 
into  the  larynx,  the  interference  with  respiration  becomes  a  sjmiptom 
of  the  greatest  importance,  as  death  often  takes  place  from  apncea. 

The  extent  of  the  diphtheritic  disease  is  very  different,  at  one 
time  being  located  merely  upon  the  tonsils  and  soft  palate,  at  another 
extending  into  the  fauc'es,  and  even  reaching  the  oesophagus,  or  the 
larynx,  as  we  have  just  remarked;  the  extension  into  the  larynx, 
with  its  attendant  serious  symptoms,  may  corne  on  suddenly  or 
insidiously. 

The  treatment  consists  in  relieving  the  local  disease  and  in  sustain- 
ing the  strength  of  the  patient.  Some  advocate  the  application  of 
lunar  caustic,  others  use  the  solution  of  perchloride  of  iron,  but  these 
means  are  often  ineffective,  they  can  only  be  applied  partially,  and 
it  is  better  to  soothe  the  mucous  membrane  by  demulcents,  by  warm 
applications,  and  by  keeping  the  fauces  as  free  and  clean  as  possible 
l>v  washing  with  a  dilute  solution  of  the  permanganate  of  potash. 
Warm  applications  should  be  applied  externally.  Chlorate  of  potash 
with  bark  are  the  best  remedies  internally,  and  a  liberal  supply  of 
nourishment  in  the  form  of  milk,  eggs,  good  soup,  &c.,  port  wine  or 
brandy  should  also  be  given. 

If  the  glands  in  the  neck  or  the  cellular  tissue  in  the  course  of 
the  Eustachian  tube  become  affected,  then  warm  applications  are 
necessary,  and  it  is  well  to  give  quinine  more  freely  as  well  as 
stimulants. 

In  diphtheria,  after  the  subsidence  of  the  more  urgent  symptoms, 
a  peculiar  form  of  paralysis  is  occasionally  developed,  and  dysphagia 
results  from  the  loss  of  power  of  the  pharyngeal  muscles.  This  con- 
dition is  very  fully  dwelt  upon  by  Maingault  in  his  valuable  treatise 
on  "Diphtheritic  Paralysis."  This  author  states  that  "the  symptoms 
of  paralysis  of  the  soft  palate  are  a  nasal  voice,  pain  on  deglutition, 
difficulty  or  impossibility  which  the  patients  experience  in  exercising 
suction,  in  distending  the  cheeks,  in  blowing  with  the  mouth,  and 
in  gargling  ;„  and,  on  examining  the  throat,  we  find  immobility  of 
the  soft  palate,  a  lengthened  condition  of  it,  numbness,  absence  of 
pain,  and  a  diminution  or  loss  of  special  sensibility.  These  various 
phenomena  supervene  a  longer  or  shorter  time  after  the  acute  affec- 
tion of  the  throat  has  been  cured;  and  when  the  pain  having  already 


48  ON    DISEASES    OF    THE    PHARYNX. 

completely  disappeared,  and  the  deglutition  having  become  easy,  the 
convalescence  is  apparently  established."  Maingault  gives  the  fol- 
lowing table  to  show  the  relative  frequency  of  the  different  forms  of 
paralysis  which  come  on  after  diphtheria : — 

Paralysis  of  the  lower  limbs         .         .         .         .13 

General  paralysis          ......     64 

Paralysis  of  the  soft  palate  .         .         .         .70 

Disordered  sensibility  without  muscular  weakness     8 
Amaurosis  .......     39 

Strabismus 10 

Paralysis  of  the  muscles  of  the  neck  and  trunk   .       9 
Anaphrodisia       .......       8 

Paralysis  of  the  bladder 4 

Paralysis  of  the  rectum 6 

He  also  adds,  that  "dysphagia  never  fails  to  come  on  whenever 
diphtheria  is  followed  by  general  paralysis."  In  the  treatment  of 
these  cases  a  very  generous  diet  is  necessary;  and,  if  deglutition  be 
impossible,  an  oesophageal  tube  should  be  used ;  electricity  has  been 
found  of  great  service,  and  tonic  remedies,  as  quinine,  steel,  &c. ; 
others  speak  very  favorable  of  the  efficacy  of  strychnia  of  nux 
vomica.  In  very  many  instances  recovery  slowly  takes  place,  but  a 
fatal  result  occasionally  ensues  from  this  complication  of  a  disease 
terribly  fatal  in  its  primary  effect.  Sir  W.  Gull1  has  recorded  an 
instance  of  this  kind  in  a  child  aged  12 ;  and  he  attributes  these 
forms  of  secondary  paralysis  to  the  extension  of  disease  to  the  spinal 
nerve  centres.2  In  the  young  patient  just  referred  to,  drooping  of 
the  head  came  on  five  weeks  after  the  attack  of  diphtheria.  The 
child  could  utter  no  sound,  and  the  diaphragm  was  unmoved  in 
respiration,  indicating  a  loss  of  power  in  the  phrenic  nerves.  Fear- 
ful attacks  of  suffocative  dyspnoea  were  produced  when  the  head  was 
moved  in  particular  situations,  and  in  one  of  these  paroxysms  he 
died. 

Phlegmonous  inflammation  or  diffuse  suppuration  is  a  very  severe 
form  of  disease,  and  is  generally  the  result  of  erysipelas,  of  pyaemia, 
sometimes  of  diphtheria  and  of  scarlet  fever.3  The  patient  rapidly 
passes  into  a  typhoid  condition,  the  dysphagia  becomes  extreme,  the 
respiration  is  impeded,  and  on  examining  the  neck  we  find  either 
erysipelatous  redness  of  the  skin  or  a  fulness  and  tenderness  among 
the  infra-hyoid  muscles,  impeding  the  free  movement  of  the  parts 
concerned  in  deglutition.  The  examination  of  the  neck  will  gene- 
rally enable  us  to  distinguish  the  dyspnoea  arising  from  this  cause 
from  that  produced  by  disease  of  the  larynx  or  trachea,  as  well  as 

1  'Lancet,'  July,  1858. 

2  Some  observations  have  lately  been  made  in  Germany  which,  so  far  as  they  go, 
seem  to  corroborate  this  opinion.     See  "  Letzerich  on  Diphtheritic  Encephalitis," 
'Virchow's  Archives,'  1875,  p.  419. 

8  It  is  called  by  the  German  authors  angina  Ludovici,  especially  when  it  attacks 
the  neck. 


ON    DISEASES    OF    THE    PHARYNX.  49 

from  that  consequent  on  pressure  or  injury  of  the  nerves  of  respira- 
tion. 

Diffused  inflammation  of  the  cellular  tissue  may  also  be  produced 
by  ulceration  in  the  mucous  membrane  of  the  pharynx. 

The  following  is  an  interesting  case  of  diffused  inflammation  of  the 
throat  : — 

CASE  I — Abraham  S — ,  aet.  36,  a  sailor  of  intemperate  habits,  was  ad- 
mitted into  Guy's  Hospital,  October  13,  1847.  On  the  5th,  whilst  unloading 
coals,  he  received  a  blow  on  the  back  of  the  hand,  and  on  the  following  day 
rigors  ensued,  with  pain  in  the  axilla,  but  the  skin  of  the  arm  did  not  become 
inflamed.  On  admission,  on  the  13th,  he  presented  the  appearance  of  a  man 
suffering  from  typhoid  fever  ;  there  was  delirium  at  night,  and  the  respiration 
was  much  oppressed ;  no  fluctuation  could  be  found  under  the  pectoral  mus- 
cle, nor  any  suppuration  detected  in  the  neck ;  the  wound  on  the  hand  was 
dry.  Stimulants  and  opium  were  administered.  On  the  loth  the  respiration 
was  difficult  and  labored,  42  per  minute ;  there  was  evident  obstruction  of  the 
larynx  and  some  tenderness  existed  about  it,  but  scarcely  any  swelling,  and 
neither  fluctuation  nor  suppuration  could  be  detected  on  very  careful  ex- 
amination ;  there  was  great  difficulty  in  swallowing.  On  the  16th  the  respi- 
ration and  deglutition  were  somewhat  easier,  but  the  skin  was  clammy  and 
the  tongue  dry.  He  died  on  the  following  day,  after  vomiting  some  blood. 
On  inspection  the  whole  of  the  cellular  tissue  surrounding  the  muscles  of  the 
neck  was  found  infiltrated  with  pus,  but  there  was  no  suppuration  below  the 
pectoral  muscles. 

CASE  II.  Diffused  inflammation  of  the  throat.  Ulceration  of  the  pharynx. 
— A  woman  admitted  into  Guy's,  in  May,  1847,  set.  66,  had  sore  throat  with 
pyrexia ;  typhoid  symptoms  quickly  followed  and  she  died  on  the  fifth  day. 
On  inspection  suppuration  was  found  among  the  muscles  of  the  neck,  and 
around  the  oesophagus  as  low  as  the  root  of  the  lung.  In  the  pharynx  there 
were  several  superficial  ulcers,  and  one  opposite  the  arytenoid  cartilage  had 
extended  into  the  cellular  tissue. 

These  diseases  appear  to  be  due  to  an  erysipelatous  form  of  inflam- 
mation, and  are  generally  so  severe  as  to  be  beyond  the  reach  of 
remedial  measures.  Ammonia  with  stimulants  should  be  freely 
administered:  quinine  in  full  doses  may  be  tried,  or  large  doses  of 
the  tincture  of  iron.  The  suppuration  is  not  sufficiently  localized  to 
admit  of  relief  by  incisions,  nor  can  remedies  be  efficiently  applied 
to  the  mucous  membranes  of  the  throat.1 

Syphilitic  ulceration  is  often  observed  in  the  throat;  it  attacks  the 
tonsils,  the  soft  palate,  the  uvula,  the  posterior  nares,  and  it  extends 
from  these  parts  to  the  posterior  wall  or  to  the  pillars  of  the  fauces ; 
when  the  ulceration  extends  from  above  it  is  well  to  raise  the  soft 
palate,  otherwise  the  ulceration  may  not  be  seen.  If  the  mischief 

1  Only  three  well-marked  cases  are  to  be  found  in  the  Guy's  post-mortem  records  in 
the  last  ten  years.  One  in  a  male,  set.  19,  under  my  colleague  Dr.  Wilks,  in  whom 
the  whole  pharynx  was  much  swollen  and  sloughing ;  the  urine  was  albuminous  ; 
death  occurred  suddenly  on  the  seventh  day.  The  second  case,  under  Dr.  Fagge, 
occurred  six  weeks  after  scarlatina.  The  sloughing  process  had  laid  bare  the  muscles 
of  the  pharynx.  The  patient  died  of  pysemia.  The  third  was  an  interesting  case  on 
account  of  the  extensive  ulceration  of  the  bowel  with  which  it  was  associated.  A  full 
report  of  it  is  published  in  the  Pathological  Society  '  Transactions'  for  1875. 
4 


50  ON    DISEASES   OF    THE    PHARYNX. 

extend  from  the  epiglottis  the  posterior  part  of  the  tongue  is  impli- 
cated. The  ulcerutiou  is  seen  to  be  circular  in  form,  and  often  ser- 
piginous  in  character.  The  disease  is  sometimes  located  quite  at 
the  commencement  of  the  oesophagus,  and  is  the  cause  of  severe 
dysphagia. 

In  the  severe  forms  of  secondary  ulceration  the  perchloride  of 
mercury  is  a  valuable  remedy,  given  alone  or  with  iodide  of  potas- 
sium. Where  there  is  chronic  and  tertiary  disease  the  iodide  is  of 
especial  service.  Tonics  alone  will  not  effectually  relieve  this  form 
of  disease,  quinine,  nitric  acid,  steel,  &c.,  may  be  used  for  weeks 
without  any  beneficial  effect,  when  the  bichloride  will  relieve  in  a 
very  short  time.  In  scrofulous  subjects1  the  disease  may  attack  the 
soft  palate  or  commence  in  the  larynx.  If  the  latter,  it  extends  to 
the  laryngeal  side  of  the  epiglottis  and  reaches  the  edge.  Dvsphagia 
is  very  severe,  and  if  the  epiglottis  is  affected  food  may  be  rejected 
even  with  violence  through  the  nares.  In  phthisis  this  ulceration  of 
the  pharynx  is  sometimes  a  most  troublesome  and  distressing  symp- 
tom; and  as  the  pneumogastric  supplies  both  the  epiglottis,  the 
lungs,  and  the  stomach,  irritation  at  the  throat  in  swallowing,  will 
produce  cough,  violent  retching,  and  vomiting.2 

Cancerous  disease  often  attacks  the  commencement  of  the  oesoph- 
agus and  the  larynx  at  the  cricoid  cartilage.  Diseases  of  this  char- 
acter extend  from  the  larynx  into  the  pharynx.  They  are  insidious 
in  their  commencement,  and  may  be  partially  relieved  by  demulcent 
and  by  soothing  treatment.  Epithelial  cancer  and  medullary  cancer 
are  the  varieties  most  frequently  met  with ;  if  the  dyspnoea  be  urgent, 
life  may  be  prolonged  by  the  performance  of  tracheotomy,  but  little, 
however,  can  be  expected  from  the  operation  of  cesophagotomy,  were 
such  an  operation  feasible. 

Suppuration  behind  the  pharynx  sometimes  occurs  in  young  chil- 
dren and  in  disease  of  the  vertebrae.  The  symptoms  produced  are 
extreme  dysphagia,  febrile  excitement,  and  exhaustion;  the  respira- 
tion is,  however,  less  impeded  in  these  cases  than  in  primary  disease 
of  the  larynx.  If  suppuration  have  taken  place  below  the  level  of 
the  soft  palate,  a  projecting  tumor  is  observed  on  examination  of  the 
throat.  The  diagnosis  is  then  sufficiently  clear;  and,  when  it  is  pos- 
sible, puncturing  the  abscess  relieves  the  urgent  symptoms.  Ab- 
scesses of  this  kind  arise  from  disease  of  the  vertebrae  or  from  local 
sources  of  irritation.  Bleuland3  mentions  fatal  dysphagia  "a  collec- 
tione  puris  inter  spinse  vertebrarurn  corpora  atque  inferiorem  pha- 
ryngis  superioremque  oesophagi  partem,"  and  Dr.  Fleming4  narrates 
several  interesting  cases  of  the  same  kind.  One  of  them  took  place 
in  a  strumous  child,  -aged  11,  in  whom  there  was  tenderness  at  the 
central  part  of  the  cervical  vertebrae;  the  tonsils  were  enlarged,  the 

1  A  scrofulous  angina  of  follicular  origin  is  described  by  Isambert,   '  Gazette  Heb- 
dom.,'  p.  757,  1871. 

2  Ulcerative  angina  sometimes  complicates  ulcerative  stomatitis  in  soldiers.    An 
epidemic  of  this  kind  is  recorded  by  Lubanski,  '  Lyon  M6dicale,'  viii,  p.  42(j. 

3  Bleuland,  '  De  sana  et  inorbasa  oesophagi  structura.' 

4  '  Dublin  Quarterly  Review.' 


ON    DISEASES    OF    THE    PHARYNX.  51 

-  -  -  -  b  v 


voice  was  nasal  and  muffled,  andthe  muscles  spasmodically  contracted. 
Those  at  the  back  of  the  neck  were/ rigid,  and,  in  speaking,  the  con- 
traction of  the  labial  and  nasal  muscles  produced  a  sort  of  tetanic 
expression;  the  jaws  could  be  separated  a  little,  and  the  tongue  could 
be  slightly  protruded.  The  abscess  was  opened  by  a  bistoury,  and 
the  child  recovered.  A  still  more  remarkable  instance  occurred  in 
an  infant  aged  two  months;  there  was  peculiar  snuffle,  difficulty  in 
deglutition,  so  that  the  child  could  scarcely  take  the  breast,  with 
occasional  dyspnoea,  and  these  symptoms  were  followed  by  convul- 
sion and  a  semi-comatose  state ;  by  pressure  of  the  finger  against  the ' 
swollen  part  in  the  pharynx  the  abscess  ruptured;  its  contents  were 
discharged  through  the  nose  and  the  infant  recovered. 

Cysts  or  pouches  are  found  especially  at  the  posterior  part  of  the 
pharynx,  and  form  cavities  varying  in  size  from  that  of  a  pea  to  a 
pigeon's  egg.  They  are  probably  the  sequel  of  glandular  disease 
and  suppuration,  and  do  not  lead  to  any  symptom.  The  pharynx  is 
sometimes  seen  to  be  one-sided  when  examined  through  the  mouth, 
and  this  distortion  is  found  in  most  cases  to  arise  from  enlarged 
glands  oa  the  outer  side  of  the  canal,  or,  again,  the  fauces  may  be 
narrowed  by  adhesion  of  the  posterior  pillars  to  the  sides  of  the 
pharynx.1 

Cancerous  disease  in  the  pharynx  is  observed  at  the  cormnencement, 
when  the  disease  is  found  to  extend  from  the  tongue  or  the  fauces, 
or  it  is  situated  at  its  termination  in  the  oesophagus,  near  to  the  cri- 
coid  cartilage.  Several  instances  of  the  latter  form  of  the  disease 
are  mentioned  with  diseases  of  the  oesophagus,  but  the  following  is 
one  in  which  cancerous  disease  began  in  the  soft  palate  and  was  asso- 
ciated with  phthisis.  Epithelioma  is  the  most  common  form  of 
malignant  disease  affecting  this  part,  but  both  medullary  and  scir- 
rhous  disease  are  sometimes  seen. 

CASE  III.  Carcinoma  of  the  Throat.  Tubercular  Pneumonia — Martha 
M — ,  jet.  31,  admitted  December  5th,  1855,  and  died  on  the  20th.  She  was 
a  short  woman,  married,  and  had  been  confined  fourteen  months  previously, 
but  since  that  time  had  not  been  well,  having  suffered  from  a  slight  cough. 
For  three  weeks  she  had  had  difficulty  in  swallowing,  and  this  had  increased 
to  such  an  extent  that  she  was,  on  admission,  unable  to  swallow  food,  except 
with  extreme  difficulty.  She  could,  with  much  distressing  pain,  swallow- 
solids,  but  fluids  were  at  once  regurgitated  through  the  nose.  She  had  suf- 
fered from  hunger,  but  still  more  from  thirst,  and  she  was  extremely  ema- 
ciated. The  glands  at  the  angle  of  the  jaw  on  the  right  side  were  much 
enlarged,  giving  her  emaciated  countenance  a  miserable  appearance.  Her 
voice  was  nasal,  and  she  was  extremely  exhausted.  She  was  too  ill  to  allow 
the  chest  to  be  examined,  and  died  on  the  20th.  Her  relatives,  brother,  &c., 
died  of  phthisis.  On  removing  the  larynx  and  tongue  the  soft  palate  was 
found  to  be  about  twice  its  natural  thickness,  irregularly  tubercular,  and 
brawny ;  the  posterior  pillars  of  the  fauces  were  affected  in  a  similar  manner 
(Preparation  178570).  On  the  right  side  there  was  a  communication  from 

1  In  Virchow's  'Archives,'  50,  161,  is  a  paper  on  warty  turners  of  the  pharynx. 
For  an  interesting  paper  on  post-pharyngeal  abscess  in  children,  see  Bokai,  '  Jahr- 
buch.  fur  Kinderheilkunde,'  Band  x. 


52  ON    DISEASES    OF    THE    PHARYNX. 

nO  BU 

theTfltyarrnx1  5-nti>  an  irregular  rarity,  situated  opposite  or  rather  behind  the 
angle  of  tin;  jaw,  about  two  inches  and  a  half  in  length,  and  half  an  inch  in 
breadth,  and  containing  almost  black  tsloughy  substance.  The  glands  were 
infiltrated  with  firm,  cancerous  product.  The  tissue  of  which  the  soft  palate 
was  composed  consisted  of  an  immense  number  of  nuclei.  In  the  lungs, 
there  were  firm  adhesions  at  the  apex  of  the  right  lung,  the  pleura  being 
semi-cartilaginous.  In  the  remaining  part  of  the  lung  numerous  minute 
tubercles  were  observed  beneath  the  pleura,  and  at  the  lower  lobe  there  were 
also  moderately  firm  adhesions.  The  left  pleura  was  free.  At  the  apex  of 
the  right  lung  was  an  irregular  vomica,  capable  of  holding  about  two  drachms 
of  fluid,  with  a  smooth  lining,  and  surrounded  by  iron-gray  lung,  with  several 
opaque  tubercles.  At  the  lower  lobe  a  considerable  portion  of  the  lung  WHS 
red  and  consolidated  ;  and  several  lobules  were  infiltrated  with  pale  yellow, 
low  organized  deposit,  which  was  breaking  down  in  several  parts,  and  pre- 
cisely resembled  the  lung  observed  in  cases  of  acute  pulmonary  phthisis. 
There  was  considerable  congestion  of  the  bronchi,  and  they  contained  tena- 
cious mucus.  The  left  lung  was  congested,  but  was  otherwise  healthy.  The 
bronchial  glands  were  black  from  pigment,  and  those  quite  at  the  base  of  the 
neck  were  firm,  white,  and  dense,  consisting  of  nuclei  resembling  those  in  the 
palate.  In  the  lung,  the  tubercles  presented  none  of  these  nuclei  nor  did 
they  consist  of  cancerous  growths,  but  were  composed  of  imperfectly  deve- 
loped nuclei,  dark  pigmental  granules,  and  some  nucleated  cells.  The  tissue 
of  the  thickened  pleura  consisted  of  fibrous  tissue.  The  heart  was  exceed- 
ingly small  and  destitute  of  fat ;  its  cavities  contained  moderately  firm  clot, 
and  the  valves  were  healthy.  The  liver,  and  also  the  spleen,  were  healthy. 
The  stomach  and  the  intestines  were  contracted  and  healthy,  except  the 
rectum  and  sigmoid  flexure,  the  mucous  membranes  of  which  were  congested 
in  longitudinal  stripes  ;  and  numerous  minute  superficial  ulcers  were  scattered 
along  these  patches. 

This  case  is'  one  of  great  interest  in  the  connection  of  cancerous 
disease  of  the  pharynx  with  tubercular  pneumonia,  diseases  rarely 
conjoined,  as  they  occur  at  different  periods  of  life,  and  are  consid- 
ered to  be  antagonistic  the  one  to  the  other.  In  advanced  life,  when 
death  has  resulted  from  cancerous  disease,  we  sometimes  find  the 
remains  of  tubercular  disease  in  the  form  of  calcareous  deposit  at  the 
apex  of  the  lung,  or  in  wasted  glands,  but  such  cases  are  rare  and 
exceptional. 


53 


CHAPTER   IY. 

ON  DISEASES  OF  THE  ffiSOPHAGUS. 

IN  the  study  of  any  local  disease  it  is  important  to  recognize  the 
tissues  of  which  that  part  is  composed,  and  to  note  the  structures 
with  which  it  is  in  contact.  Morbid  processes  extend  to  contiguous 
parts,  and  the  knowledge  of  the  diseases  of  one  organ  may  serve  as 
an  important  guide  in  the  investigation  of  a  neighboring  one  into 
which  the  structures  merge.  In  the  last  chapter  we  described  the 
diseases  of  the  mouth  and  throat,  and  there  is  much  similarity  in 
some  of  the  tissues  prolonged  into  the  oesophagus;  but  whilst  the 
mucous  membrane  is  covered  by  the  same  kind  of  scaly  epithelium, 
it  is  of  a  more  simple  character.  It  has  a  large  number  of  conical 
papillas,  which  project  into  the  epithelial  layer,  but  it  is  destitute  of 
the  abundance  of  secreting  follicles  existing  in  the  mouth  and  throat, 
although  some  isolated  submucous  glands  of  an  acinous  character 
may  still  be  found.  The  mucous  membrane  is  more  free,  and  is 
separated  by  a  layer  of  connective  tissue  from  the  muscular  coat, 
which  is  composed  of  longitudinal  and  circular  bands.  With  this 
greater  simplicity  of  structure  there  is  associated  less  activity  of 
function,  and  di/ninished  severity  of  disease;  thus,  some  of  the  affec- 
tions of  the  mouth  and  throat  which  are  dependent  upon  abnormali- 
ties of  the  secreting  parts  are  entirely  absent,  whilst  the  greater 
predominance  of  muscular  action,  which  may  be  regarded  as  the 
prominent  function  of  the  oesophagus,  leads  to  alterations  of  muscular 
energy  and  to  obstruction  of  a  functional  or  organic  character. 

The  oesophagus  extends  from  the  fifth  cervical  to  the  ninth  dorsal 
vertebra,  and  it  is  in  this  region  that  auscultation,  if  of  any  practical 
value,  may  be  applied  to  the  elucidation  of  its  diseases.  Inclining  a 
little  to  the  left  of  the  vertebral  spine  soon  after  its  commencement, 
the  oesophagus  gradually  passes  again  to  the  median  line,  and  after- 
wards a  second  time  to  the  left  as  it  reaches  its  diaphragmatic  ter- 
mination in  the  stomach.  The  canal  is  narrowed  at  the  latter  part, 
at  the  diaphragm,  so  also  at  its  commencement  behind  the  cricoid 
cartilage  of  the  larynx,  and  again  at  the  root  of  the  lung.  It  is  in 
relation  in  front  with  the  trachea,  with  the  arch  of  the  aorta,  the  left 
bronchus,  and  with  the  posterior  surface  of  the  heart  (left  auricle); 
at  its  upper  part,  on  either  side,  the  recurrent  laryngeal  nerves  are 
placed  between  it  and  the  trachea,  and  below,  the  pneumogastric 
nerves  descend  in  close  contact  with  it.  At  the  posterior  part  of 
the  oesophagus  the  nerves  unite  to  form  a  plexus  (plexus  gulae),  and 
they  also  receive  filaments  from  the  cardiac  nerves  of  the  sympa- 
thetic. 


54  ON    DISEASES    OF    THE    (ESOPHAGUS. 

In  the  consideration  of  the  diseases  of  the  oesophagus  we  shall 
describe — 

I.  Diseases  of  the  mucous  membrane. 
Inflammation. 

Ulceration. 
Abscesses  and  cysts. 
Warty  growths. 

II.  Alterations  in  the  muscular  coat. 
Spasmodic  contraction. 
Paralysis. 

Hypertrophy  and  dilatation -pouches. 

III.  Obstructions. 
Internal. 

From  annular  constriction. 
From  syphilis. 

From  ulceration  and  cicatrices. 
From  cancerous  disease. 
External. 

From  pressure  of  aneurismal  or  mediastinal  tumors. 
From  disease  of  the  glands. 

From  effusions  into  the  pleura  and  pericardium,  and  from  in- 
flammation in  the  mediastinum. 
From  abnormal  arrangement  of  vessels. 

IV.  The  effects  of  corrosive  poisons. 

V.  Foreign  bodies  producing  obstruction. 

VI.  Hemorrhage  and  ecchymosis. 

VII.  Rupture. 

VIII.  Gastric  solution. 

The  function  of  the  oesophagus  is  of  so  simple  a  character,  and  the 
transit  of  food  over  its  mucous  surface  is  so  rapid,  that  it  is  less  sub- 
ject to  organic  disease  than  some  other  parts  of  the  alimentary  tract. 
The  process  of  swallowing  is  dependent  in  great  part  upon  its  func 
tional  integrity,  and  cannot  indeed  be  said  to  be  completed  till  the 
food  reaches  the  stomach  ;  hence  it  is  that  dysphagia  becomes  one  of 
the  most  prominent  symptoms  of  disease,  not  only  of  the  pharynx, 
but  also  of  the  oesophagus. 

In  the  diseases  of  the  mouth,  the  tongue,  and  the  fauces,  which 
we  have  already  mentioned,  there  is  an  interference  with  the  first 
part  of  the  act  of  deglutition,  so  also  in  morbid  conditions  of  the 
pharynx  and  also  of  the  larynx ;  but  in  the  affections  of  the  oeso- 
phagus it  is  the  latter  portion  of  the  process  of  swallowing  that  is 
hindered. 

I.  Diseases  of  the  mucous  membrane. — Acute  inflammation  of  the 
mucous  membrane  of  the  oesophagus  is  a  very  rare  disease.  It  is 
described  by  some  authors,1  and  dysphagia  is  mentioned  amongst  its 

1  Cases  of  diphtheritic  inflammation  extending  to  the  oesophagus  are  to  he  found  in 
'Path.  Soc.  Trans.'  Galen  Blueland,  '  DC  sana  et  morhosa  structura  o-sophagi :' 
Mondiere,  '  Arch.  Gen.  de  Med.,'  torn,  xxx ;  'Diet,  de  M6d.  et  de  Chir.  Pratique ;' 
Copland,  'Med.  Diet.' 


ON    DISEASES    OF    THE    (ESOPHAGUS.  55 

symptoms.  Excepting  those  cases  in  which  irritant  substances  have 
been  swallowed,  and  others  also  of  gastro-enteric  inflammation  in 
children,  we  have  only  seen  two  instances  in  which  acute  oesopha- 
gitis  could  be  said  to  exist.  One,  a  man,  set.  38,  had  gangrene  of  the 
penis  associated  with  purpura  and  a  diphtheritic  state  of  the  fauces. 
The  oesophagus  was  much  thickened,  its  longitudinal  ridges  were 
too  distinct,  and  its  color  was  of  an  inky  black.  The  stomach  was 
much  injected  and  the  intestines  throughout  were  in  a  state  of  acute 
inflammation.  The  second  case  occurred  in  association  with  phthisis 
in  a  boy,  let.  10,  who  gave  no  history  of  dysphagia ;  yet  the  oesopha- 
gus throughout  its  whole  length  was  yellow  and  shaggy,  and  in  a 
state  precisely  corresponding  to  that  known  in  the  urethra  as  stru- 
mous  disease.  The  larynx  was  in  a  like  state.  The  stomach  was 
healthy.  A  similar  case  is  recorded  by  Abercrombie,  in  which  a 
soft  adventitious  membrane  could  be  traced  from  the  pharynx  to  the 
cardia,  and  the  pharynx  and  epiglottis  were  covered  with  a  similar 
membrane.  The  patient,  a  gentleman,  aet.  26,  had  swelling  of  the 
side  of  the  neck,  hoarseness,  some  dyspnoea,  dysphagia,  and  febrile 
excitement,  followed  by  typhoid  prostration.  The  throat  was  red, 
and  aphthous  crusts  were  observed  on  the  mucous  membrane.  Death 
took  place  in  three  weeks. 

In  case  of  acute  inflammation  of  both  the  small  and  large  intes- 
tines of  a  diphtheritic  character,  admitted  under  my  care  into  Guy's 
Hospital,  during  1855,  the  mouth  was  inflamed,  and  the  pharynx 
and  tonsils  were  covered  with  a  white  film,  spread  upon  an  injected 
mucous  membrane.  This  white  film  consisted  of  a  beautiful  torula, 
interlacing  in  all  directions,  constituting  the  "muyuet;"  it  extended 
downwards  to  the  commencement  of  the  oesophagus,  and  some  traces 
of  it  were  found  in  that  canal.  In  this  instance,  the  symptoms  were 
those  of  dysenteric  diarrhoea,  which  had  come  on  several  months 
before  the  woman's  admission  into  Guy's,  and  had  persisted  without 
any  intermission  for  seven  weeks.  The  disease  was  attributed  to  her 
removal  into  a  damp  house.  The  patient  was  exceedingly  prostrate ; 
she  had  severe  vomiting,  and  whenever  she  attempted  to  take  food 
retching  and  acute  pain  were  produced.  No  medicines  nor  injections 
had  any  effect  in  checking  the  diarrhoea,  and  she  died  on  the  third 
day  after  admission.  The  mucous  membrane  of  the  oesophagus  was, 
perhaps,  equally  affected  with  that  of  the  mouth  and  pharynx ;  and, 
indeed,  it  appeared  that  the  whole  tract  of  the  alimentary  canal  from 
the  mouth  to  the  rectum  was  inflamed.1 

It  is  probable,  that  in  some  of  the  cases  of  severe  gastro-enteritis 
in  children,  in  whom  the  mouth  as  well  as  the  intestine  is  evidently 
inflamed,  the  whole  of  the  alimentary  tract  is  affected,  and  would 
present  before  death  a  condition  quite  abnormal.  At  the  close  of 
chronic  disease,  we  find  a  similar  condition  of  the  pharynx,  rendering 

1  See  dysentery,  for  a  more  full  account  of  this  case.  Steffen  ('  Jahrb.  fur  Kinder- 
heilkrank.,'  vol.  ii,  p.  143)  gives  forty-four  cases  of  disease  of  the  cesophagiis  in 
children  ;  hypersemia,  catarrh,  and  follicular  ulceration  were  present  several  times, 
as  well  as  croup  and  diphtheria ;  thrush  was  found  twice,  and  when  this  existed  a 
similar  state  was  also  found  in  the  stomach. 


56  ON    DISEASES    OF    THE    (ESOPHAGUS. 

deglutition  both  painful  and  difficult;  aphthous  inflammation  of  the 
mouth  having  extended  into  this  part.  In  these  conditions,  I  have 
not  seen  any  remedy  followed  by  such  beneficial  effects  as  the  chlo- 
rate of  potash,  associated  sometimes  with  borax  and  honey ;  but 
alone  it  often  acts  apparently  in  a  most  marked  manner.  This 
remedy  in  stomatitis,  introduced  I  believe  by  Hunt,  was  very  ex- 
tensively used  by  the  late  Dr.  Golding-Bird,  and  subsequent  observers 
have  confirmed  the  favorable  opinion  which  he  entertained.  It  ap- 
pears to  act  partly  by  its  local  effect,  and  also  as  a  saline  after  its 
absorption  into  the  system. 

Ulceration  is  generally  due  to  syphilis  or  to  cancerous  disease,  but 
it  occasionally  occurs  without  any  evidence  that  it  is  due  to  either  of 
these  diseases;  still,  whatever  may  be  the  cause  of  the  ulceration  of 
the  oesophagus,  its  close  proximity  to  the  trachea  leads  occasionally 
to  perforation  of  the  latter  and  to  consequent  symptoms. 

In  the  Museum  at  Guy's  Hospital,  there  are  several  specimens 
showing  ulceration  of  the  oesophagus,  of  a  non-cancerous  character, 
extending  into  the  trachea,  and  there  is  some  obscurity  as  to  their 
correct  pathology.1  Difficulty  of  deglutition  is  the  most  prominent 
symptom  during  life  in  these  cases ;  in  some,  dysphagia  is  gradually 
developed,  in  others,  deglutition  suddenly  becomes  impossible.  The 
patients  complain  of  pain  at  the  sternum  or  between  the  shoulders; 
and  on  attempting  to  swallow  urgent  dyspnoea  comes  on,  with  the 
forcible  ejection  of  food  through  the  nares.  The  patients  become 
emaciated,  and  life  is  only  prolonged  for  a  short  time  by  the  use  of 
nutrient  enemata.  On  inspection  after  death,  the  only  disease  found 
has  been  a  perforation  of  the  oesophagus  opening  into  the  trachea; 
the  openings,  two  or  three  in  number,  extended  over  one  or  two 
inches,  their  edges  were  smooth,  and  without  any  thickening;  and  in 
several  cases  the  opening  into  the  trachea  was  smaller  than  that  into 
the  oesophagus.  The  examination  of  these  cases  does  not  give  any 
evidence  of  cancerous  disease ;  nor  do  we  find -other  signs  of  disease, 
either  in  the  larynx  or  in  the  lungs;  the  early  symptoms  appear  to 
arise  from  the  oesophagus,  the  difficulty  in  respiration  following  that 
of  deglutition.  These  facts  appear  to  show  that  the  disease  has  not 
commenced  either  in  the  mucous  membrane  of  the  trachea  nor  in 
disease  of  its  cartilages;  and  we  are  led  to  suppose,  either,  that  an 
abscess  has  formed  between  the  oesophagus  and  trachea,  and  led  to 
fistulous  openings  into  those  canals,  or  that  ulceration  has  taken 
place  in  the  oesophagus,  and  gradually  extended  in  depth  through 
the  adjoining  structures.  It  sometimes,  however,  happens  that 
ulceration  extending  into  the  oesophagus  arises  from  diseases  of  the 
trachial  cartilages,  and  the  following  remarkable  specimen  is  of  that 
kind: — 

CASE  IV.  Diseased  .  Cartilages  of  the  Trachea.  Ulceration  of  the  (Eso- 
phagus— A  carrier,  aet.  42,  at  Hampton,  came  under  the  care  of  Mr.  Hol- 
leston  and  Mr.  Jepson,  in  1853,  for  crowing  respiration,  with  abundant 
expectoration,  but  no  very  urgent  dyspnoea,  nor  difficulty  in  swallowing.  He 

1  Case  by  Dr.  Peacock,  '  Path.  Soc.  Trans.,'  vol.  xvii,  186.6,  p.  119. 


ON    DISEASES    OF    THE    (ESOPHAGUS.  57 

gradually  sank  ;  but  six  months  before  his  death  he  expectorated  a  portion  of 
ossified  tracheal  cartilage  (Preparation  171 187),  and  six  weeks  later  a  second 
portion.  On  inspection,  at  the  commencement  of  the  oesophagus,  immediately 
beneath  the  cricoid  cartilage,  a  vertical  opening,  half  an  inch  in  length,  with 
smooth  and  rounded  edges,  was  found  to  extend  into  the  trachea ;  there  were 
three  other  communications  resembling  fissures,  merely  separated  from  each 
other  by  shreds  of  mucous  membrane.  The  cartilages  of  the  trachea  were 
ossified,  and  there  was  ulceration  of  the  mucous  membrane  of  the  larynx  at 
the  cricoid  cartilage.  The  inferior  lobe  of  the  right  lung  was  consolidated, 
but  no  other  part  of  the  body  was  diseased ;  and  there  was  no  trace  of  can- 
cerous nor  of  strumous  disease. 

Dysphagia  was  almost  absent,  as  far  as  can  be  learned,  in  this  case, 
and  the  symptoms  were  those  indicative  of  disease  commencing  in 
the  larynx;  thus  differing  remarkably  from  the  cases  presently  to  be 
recorded,  where  dysphagia  was  the  most  prominent  complaint  of  the 
patient.  It  is  probable  that  their  pathology  is  also  different.  No 
history  of  syphilis  is  given,  but  the  expectoration  of  a  portion  of 
diseased  cartilage,  six  months  before  death,  indicated  the  character 
of  the  disease. 

CASE  V.    Ulceration  of  the  (Esophagus.     Perforation  of  the   Trachea 

A  married  woman,  set.  24,  who  had  never  enjoyed  robust  health,  about  a 
year  previous  to  her  admission  under  Dr.  Barlow's  care,  had  enlarged  glands 
of  the  neck,  which  diminished  under  the  use  of  iodine.  Six  months  after- 
wards she  began  to  experience  difficulty  in  swallowing,  with  pain  in  the  chest, 
uneasiness  in  the  throat,  and  shortness  of  breath.  These  symptoms  increased 
in  severity  till  admission,  but  a  short  time  previously  they  had  suddenly  be- 
come very  much  aggravated.  She  was  much  emaciated ;  no  swelling  could 
be  found  about  the  neck,  nor  any  disease  detected  in  the  chest.  She  ex- 
perienced the  greatest  difficulty  in  swallowing  fluids,  and  food  was  at  once 
forcibly  ejected.  Mr.  Hilton  passed  an  oesophageal  tube,  and  found  that 
when  the  patient  breathed,  air  passed  through  the  tube,  indicating  a  com- 
munication with  the  trachea.  She  was  fed  for  six  weeks  entirely  by  injections. 
On  inspection,  the  trachea  and  oasophagus  were  found  extensively  diseased 
from  the  level  of  the  cricoid  cartilage,  nearly  as  far  as  the  bifurcation  of  the 
trachea,  and  the  two  canals  communicated  by  three  openings.  The  anterior 
Avail  of  the  oesophagus  near  its  commencement  was  destroyed,  with  the  ex- 
ception of  two  slips  of  muscle,  which  still  remained  ;  and  at  this  part  there 
was  an  oval  ulcerated  opening  passing  into  the  trachea ;  below  this  a  small 
portion  of  the  calibre  of  the  oesophagus  was  considerably  contracted ;  still 
lower  the  oesophagus  was  again  destroyed,  and  two  more  openings  passed  into 
the  trachea.  At  this  latter  part,  the  posterior  wall  of  the  oesophagus  was 
also  destroyed,  and  the  body  of  the  last  cervical  vertebra  was  exposed  ;  so  that 
an  abscess  had  been  formed  bounded  by  the  cellular  tissue  of  the  trachea,  by 
the  remains  of  the  oesophagus,  and  by  the  muscle  of  the  neck.  The  openings 
into  the  trachea  were  oval,  transverse,  perfectly  smooth,  and  covered  with 
mucous,  and  not  the  least  thickening  nor  heterologous  deposit  could  be  de- 
tected by  careful  examination,  aided  by  the  microscope.  In  the  ovary,  and 
in  an  adhesion  on  the  surface  of  the  liver,  there  were  slight  strumous  granu- 
lar deposits  ;  the  other  viscera  were  healthy,  and  there  was  no  evidence  of 
cancerous  disease.  There  was  difficulty  in  breathing,  and  Mr.  Hilton  per- 
formed tracheotomy,  but  without  any  permanent  advantage  to  the  patient. 
(See  Preparation  1714'°,  and  drawing  26424.)  The  stomach  was  small,  con- 


58  ON    DISEASES    OF    THE    (ESOPHAGUS. 

tracted,  and  almost  perpendicular ;  it  contained  a  small  quantity  of  bilious- 
looking  alkaline  mucus.  The  large  intestine  was  dilated,  and  contained 
healthy  feces;  the  caecum  contained  some  acid  mucus;  the  rectum  presented 
several  small  ulcers,  and  was  covered  by  a  firmly  adherent  diphtheritic 
deposit. 

The  following  case  occurred  in  Guy's,  in  the  year  1840.  There  is 
no  history  of  the  symptoms  on  record ;  but  the  patient  was  a  man 
set.  33,  and  he  died  four  days  after  admission.  The  post-mortem 
inspection  was  as  follows  : 

The  body  was  exceedingly  emaciated.  Near  the  middle  of  the  oesophagus 
the  mucous  membrane,  for  about  two  inches,  was  of  a  very  red  color,  and 
irregular  from  ulceration;  the  canal  was  much  contracted,  and  would  have 
scarcely  admitted  the  end  of  the  little  finger.  Below  the  stricture  the 
oesophagus  was  much  dilated,  and  an  abscess  had  formed  behind  it,  containing 
four  ounces  of  a  dark  fluid  of  a  sour  odor ;  there  was  a  small  sinus  leading  to 
the  abscess ;  the  mucous  membrane,  both  above  and  below  the  diseased  part, 
was  quite  healthy  ;  there  was  no  evidence  of  cancer  in  the  affected  part,  nor 
was  any  other  organ  diseased,  except  that  the  kidneys  were  found  to  be 
granular.  (See  Preparation  178957.)  It  was  supposed  that  a  corrosive 
poison  must  have  been  taken,  but  of  this  there  was  no  evidence. 

An  exceedingly  interesting  record  will  be  found  in  the  'Patholo- 
gical Transactions'  for  1852,  by  Mr.  ~W.  Trotter.  A  young  woman, 
in  St.  Mary's  Hospital,  set.  25,  had  ulceration  of  the  oesophagus, 
which  extended  into  the  pericardium,  and  led  to  sudden  syncope  and 
death.  For  three  months  she  had  had  nausea,  dysphagia,  occasional 
vomiting,  and  pain  at  the  top  of  the  sternum,  and  at  the  epigastrium. 
Solids  were  swallowed  with  much  difficulty.  There  was  found,  after 
death,  simple  ulceration  without  contraction  ;  the  ulcer  had  extended 
from  the  bifurcation  of  the  trachea  nearly  to  the  diaphragm,  and  had 
perforated  the  pericardium.  No  other  organ  was  diseased. 

The  last  two  cases  were  instances  of  simple  ulceration  below  the 
bifurcation  of  the  trachea ;  in  the  others  the  disease  was  above  this 
part ;  still,  they  appear  very  similar  in  character,  and  the  modifica- 
tion in  the  symptoms  arose  from  the  difference  of  the  structures 
which  were  implicated. 

There  are  many  instances  of  pain  at  the  upper  part  of  the  sternum 
on  swallowing,  when  no  trace  of  pressure  nor  aneurism  can  be  found; 
and  I  have  seen  this  sympton  disappear  under  the  use  of  tonics, 
sometimes  with  iodide  of  potassium.  The  idea  of  cancerous  growth 
has  been  precluded,  and  it  has  been  therefore  a  question  whether 
some  abrasion  of  the  mucous  membrane,  or  slight  ulceration,  such 
as  we  sometimes  find  in  the  pharynx,  had  not  led  to  this  complaint. 

It  is  exceedingly  difficult,  during  life,  to  decide  as  to  the  character 
of  these  cases  of  simple  ulceration :  the  emaciation,  dysphagia,  and 
distress  being  the  same  as  in  cancerous  disease.  In  all  the  cases 
which  have  come  within  my  notice,  the  age  of  the  patient  has  been 
very  much  less  than  in  those  instances  in  which  cancer  occurred. 
This  alone,  however,  is  not  sufficient  to  enable  us  to  decide  with 
certainty  as  to  the  character  of  the  disease. 


ON    DISEASES    OF    THE    (ESOPHAGUS.  59 

The  treatment  is  exceedingly  unsatisfactory;  the  spasmodic  con- 
traction of  the  ulcerated  part  prevents  the  passage  of  cesophageal 
tubes;  no  food  can  be  swallowed,  and  the  administration  of  nutrient 
enemata  prolongs  life  only  for  a  few  days  or  ^veeks.  It  is  painful  to 
find,  after  death,  that  simple  ulceration  of  the  oesophagus,  or  a  fistu- 
lous  communication  with  the  trachea,  is  the  only  existing  disease; 
and  that  if  food  could  have  been  introduced  beyond  this  point,  life 
might  have  been  prolonged.  The  operation  of  oesophagotomy  is  a 
very  difficult  one,  and  in  many  of  these  cases,  if  performed,  would 
be  quite  ineffective,  because  the  disease  is- often  situated  at  the  root 
of  the  lung,  or  behind  the  first  bone  of  the  sternum;  in  either  case, 
the  operation  could  not  be  performed  below  the  seat  of  stricture. 
Now  that  it  has  been  practically  shown  that  the  peritoneum  may  be 
divided  without  fatal  result,  and  without  the  terrible  effect  seen  to 
follow  from  ruptured  viscera,  the  propriety  of  forming  a  gastric  fistula 
in  some  of  these  cases  is  worthy  of  very  serious  consideration.  An 
operation  of  this  kind  appears  certainly  warrantable,  as  it  would 
afford  a  chance  of  life  to  those  who  have  only  the  prospect  of  certain 
death.  In  the  human  subject,  several  cases  of  gastric  fistula  acci- 
dentally produced  have  been  recorded,  and  experimenters  on  animals 
have  purposely  made  such  openings,  under  the  influence  of  chloro- 
form, without  the  production  of  severe  peritonitis.  Since  the  first 
edition  of  this  work  was  published,  a  gastric  fistula  has  been  made 
in  many  cases,  although  as  yet  only  in  one  or  two  instances  with 
success ;  the  first  was  upon  a  patient  of  my  own,  and  I  suggested  the 
operation  to  relieve  the  agonizing  distress  of  starvation  in  a  man 
dying  from  cancerous  occlusion  of  the  oesophagus.  (See  cases  of 
cancer.) 

Syphilitic  ulceration  so  generally  leads  to  more  or  less  obstruction 
that  it  may  advantageously  be  left  till  we  come  to  treat  of  stricture. 

Abscesses. — Local  suppuration  in  the  submucous  tissue  of  the 
oesophagus  sometimes  occurs  and  produces  dysphagia,  or  rather  the 
regurgitation  of  food,  as  in  cases  of  organic  obstruction.  Two  such 
are  recorded  in  the  Guy's  post-mortem  records;  both  were  of  small 
size  and  of  no  real  moment.  They  are  rare  and  obscure  in  character, 
and  the  febrile  disturbance  is  not  sufficiently  distinctive  of  the  nature 
of  the  affection.  Diseased  glands  may  set  up  this  local  abscess,  as 
well  as  the  annular  stricture  to  which  we  have  presently  to  refer. 

Cysts  in  connection  with  the  oesophagus  rarely  occur;  but  small 
pouches  dependent  upon  local  dilatation  of  follicles  may  be  found, 
and  occasionally  a  cyst  is  discovered  full  of  mucus;  a  case  of  this 
kind  was  observed  at  Guy's  last  year,  in  which  the  contents  of  the 
sac  were  mucoid,  but  the  swelling  had  not  given  rise  to  any  symp- 
toms. 

Warty  conditions  of  the  lining  membrane  are  of  pathological  rather 
than  of  clinical  import ;  it  has  not  been  found  that  their  presence  has 
caused  serious  obstruction,  or  that  any  symptom  indicating  their 
existence  was  produced.  They  are  for  the  most  part  small,  and  con- 
sist of  flat,  grain-like  projections  from  the  surface,  which  may  easily 
be  overlooked  by  a  casual  observer.  These  warty  growths  are  not 


60  ON    DISEASES    OF    THE    (ESOPHAGUS. 

uncommon;  of  thirteen  cases  recorded  in  our  reports,  they  occurred 
no  less  than  eight  times  in  association  with  heart  disease;  in  one 
instance  the  patient  suffered  from  phthisis,  in  two  from  Bright's  dis- 
ease, and  in  one  from  some  form  of  psoriasis.  This  large  prepon- 
derance in  heart  disease  suggests  that  chronic  congestion  of  the  coats 
of  the  oesophagus,  from  the  disturbed  circulation,  acted  as  the  predis- 
posing cause;  in  other  instances  there  is  an  abnormal  tendency  to  the 
growth  of  the  papillary  structures  in  this  part.  In  the  lower  animals 
a  very  remarkable  condition  of  the  kind  has  been  found,  especially 
in  oxen,  the  whole  mucous  surface  being  covered  over  with  larger  or 
smaller  pedunculated  cauliflower  excrescences,  of  very  horny  texture. 
One  of  these  cases  is  to  be  found  in  the  Museum  of  Guy's  Hospital, 
a  second  in  the  Hunterian  Museum  of  the  Royal  College  of  Surgeons, 
and  a  third  was  in  a  man,  whose  case  is  published  by  Luschka.1 
These  instances  correspond  to  the  papillary  tumor  of  the  pharynx 
previously  alluded  to. 

II.  Another  important  class  of  cesophageal  diseases  includes  affec- 
tions of  its  muscular  and  external  coat.  All  disordered  muscular 
action  of  the  oesophagus  produces  dysphagia,  but  this  important 
symptom  arises  from  various  causes,  which  may  be  classified  in  the 
following  manner:  dysphagia  arising  from 

1.  Diseases  of  the  structures  connected  with  the  first  part  of  the 
act  of  deglutition,  affecting  the  tongue,  the  tonsils,  the  fauces,  &c. 

2.  Diseases  of  the  pharynx. 

These  two  groups  include  glossitis  in  its  several  forms — tonsillitis, 
scarlatinal  and  diphtheritic  affections,  acute  inflammatory  states  of 
the  fauces,  strumous,  syphilitic,  and  cancerous  ulceratious;  these 
have  been  already  described. 

3.  Diseases  of  the  larynx,  as  laryngitis  and  croup;  ulcerations  of 
the  epiglottis  and  laryngeal  cartilages,  whether  strumous,  syphilitic, 
or  cancerous;  tracheal  affections. 

4.  Inflammation  and  ulceration  of  the  mucous  layer. 

5.  Functional  disorders  of  the  muscular  coat,  especially  cases  of 
spasmodic  stricture  of  the  oesophagus  and  pharynx. 

6.  Paralysis  of  the  muscles  of  deglutition. 

7.  Organic  stricture  from  annular  constriction,  from  syphilitis, 
from  cicatrices,  from  cancerous  disease. 

8. .  Obstruction  by  pressure  from  without. 

9.  Contraction  as  the  effect  of  corrosive  poisons. 

10.  Mechanical  injury  and  foreign  bodies  in  the  passage. 
Dysphagia  from  several  of  these  causes  has  already  been  noticed, 

and  we  shall  now  have  to  consider  the  same  symptom  under  other 
conditions  of  disease.  Before,  however,  speaking  of  difficulty  of 
deglutition  as  due  to  a  changed  state  of  the  muscular  fibre,  it  may 
be  well  to  advert  to  those  instances  where  it  is  produced  by  affec- 
tions of  the  larynx  and  trachea. 

1  'Virchow's  Jahrbuch,' loc.  cit. 


ON    DISEASES    OF    THE    (ESOPHAGUS.  61 

Laryngeal  Dysphagia.-— In  acute  laryngitis  and  in  croup,  it  is  the 
exception  to  find  deglutition  performed  in  the  normal  manner;  and 
sometimes,  especially  in  laryngitis,  dysphagia  is  an  urgent  symptom. 
In  these  cases,  however,  the  dyspnoea  and  cough  are  the  earlier  and 
the  more  marked  indications  of  disease.  The  epiglottis  is  found  to 
be  injected  and  tumid,  and  the  branches  of  the  superior  laryngeal 
nerve  are  rendered  intensely  sensitive.  This  abnormal  sensibility 
affords  an  explanation  of  the  dysphagia  which  is  generally  present, 
even  if  the  mischief  do  not  spread  directly  to  the  pharynx. 

Diseases  of  the  laryngeal  cartilages  rarely  extend  to  the  pharynx, 
unless  the  malady  be  of  a  cancerons  character;  more  frequentlv,  as 
in  necrosis,  suppuration  takes  place  among  the  muscles  of  the  neck, 
and  chronic  laryngitis  of  a  most  intractable  form  is  produced.  But 
although  dysphagia  is  not  a  prominent  symptom  of  disease  when 
only  the  cartilages  of  the  larynx  are  affected,  the  reverse  is  the  case 
when  the  fibre-cartilage,  the  epiglottis,  is  also  implicated,  whether 
in  syphilitic,  in  strumous,  or  in  cancerous  diseases. 

In  syphilis,  both  the  glossal  and  laryngeal  surfaces  of  the  epiglottis 
become  involved,  and  sometimes  nearly  the  whole  of  the  fibro-car- 
tilage  is  destroyed,  leading  to  distressing  dysphagia;  and  in  phthisis 
ulceration  of  the  epiglottis  is  one  of  the  most  trying  complications 
of  the  complaint,  the  ulceration  extending  on  its  inner  surface  as  far 
as  the  margin,  which  becomes  eroded  and  gradually  destroyed,  and 
the  contact  of  food  with  this  irritated  surface  sometimes  leads  to  the 
instant  rejection  of  it  through  the  nares.  In  chronic  phthisis  I  have 
seen  this  condition  attributed  to  organic  disease  of  the  O3sophagus 
itself,  on  account  of  the  extreme  urgency  of  the  dysphagia,  and 
because  the  food  appeared  to  have  passed  below  the  pharynx  before 
it  was  forcibly  ejected.  It  sometimes  happens  that  solids  are  more 
easily  swallowed  than  fluids;  and  this  is  the  case  in  some  instances 
where  the  dysphagia  arises  from  disease  of  the  larynx;  a  solid  will 
pass  over  the  diseased  epiglottis  and  fall  beyond  it,  whilst  a  fluid 
comes  in  close  contact  with  it. 

Laryngeal  dysphagia  is  often  greatly  mitigated  by  the  inhalation 
of  steam,  or  of  the  fumes  from  coniurn  or  stramonium.  In  less  severe 
cases  astringent  gargles,  and  in  syphilitic  ulceration  the  application 
of  a  strong  solution  of  nitrate  of  silver,  afford  relief  by  diminishing 
the  extreme  sensibility  of  the  diseased  surface.  Counter-irritation 
may  occasionally  be  applied  with  advantage,  as  the  tincture  of  iodine, 
hot  fomentations,  cantharides,  &c.  The  improval  of  health  by  resi- 
dence at  the  sea-coast,  by  cod-liver  oil,  by  preparations  of  iodine,  and 
of  steel,  and  by  the  use  of  such  forms  of  nutritious  diet  as  can  be 
taken  by  the  patient,  are  the  means  most  likely  to  be  followed  by 
enduring  benefit. 

With  this  form  of  dysphagia  may  be  associated  those  instances  in 
which  inflammation  of 'the  trachea  is  the  cause  of  the  symptom,  and 
this  has  been  described  by  Dr.  Hyde  Salter1  as  "  Tracheal  dysphagia." 
The  complication  of  a  purely  cesophageal  disease  has  been  referred 
to  a  stretching  of  the  inflamed  tracheal  surface  during  deglutition  ; 

>  Dr.  Hyde  Salter,  '  Lancet,'  1864,  vol.  ii. 


62  ON    DISEASES    OP    THE    (ESOPHAGUS. 

but  this  would  equally  apply  to  inflamed  and  swollen  bronchial 
glands,  in  which  condition  no  such  symptom  is  produced ;  and  it  is 
more  probable  that  this  symptom  is  due  to  the  reflex  action  of  the 
pneurnogastric  nerve.  Tracheal  dysphagia  is  best  treated  by  inha- 
lations of  soothing  remedies,  as  steam,  alone  or  with  ipecacuanha,  or 
with  hemlock  juice,  and  by  the  internal  administration  of  salines, 
with  ipecacuanha  or  antimony. 

The  affections  which  now  come  before  us  are  connected  with  the 
nervous  supply  of  the  part,  and  with  the  mental  condition  of  the 
patient ;  they  are  spoken  of  as  spasmodic  dysphagia  or  spasmodic  st  r/<-l- 
ure.  In  globus  hystericus  a  sensation  is  produced  as  of  a  ball  being 
lodged  in  the  throat,  with  a  painful  feeling  of  suffocation  ;  it  comes  on 
suddenly  after  emotional  excitement  or  distress,  and  is  oftena  symptom 
of  an  attack  of  hysteria,  in  persons  suffering  from  general  debility, 
and  especially  where  there  is  disturbance  of  the  uterine  functions. 
The  supposed  obstruction  to  the  passage  disappears  when  the  attempt 
is  made  to  swallow  food.  In  other  cases  the  sense  of  cesophageal  ob- 
struction is  due  to  flatulence  and  to  distension  of  the  stomach,  and  is 
relieved  by  the  removal  of  flatus.  Again,  in  irritability  of  the  heart 
with  exhaustion,  we  occasionally  find  the  same  sensation  of  obstruc- 
tion and  spasmodic  choking.  It  would  seern  that  in  these  latter  cases 
the  recurrent  nerve  as  well  as  the  cesophageal  branchesare  implicated, 
for  there  is  greater  and  more  sudden  distress  of  breathing  than  in 
simple  flatulence.  The  condition  here  referred  to  is  one  quite  dis- 
tinct from  angina  pectoris,  as  well  as  from  the  severe  dyspnoea  of 
organic  disease  of  the  heart  and  cardiac  asthma.  It  is  a  curable  state, 
and  one  that  ceases  when  strength  is  restored.  It  is  found  sometimes 
in  patients  who  have  suffered  from  nienorrhagia  or  other  causes  of 
exhaustion,  and  in  whom  the  heart  is  free  from  organic  disease, 
although  the  vessels  may  be  more  rigid  and  atherornatous  than  in 
earlier  life. 

In  severe  spinal  disease  there  is  also  occasionally  present  a  nervous 
dysphagia,  which  aggravates  the  distress  of  the  patient.  Another 
class  of  cases  is  connected  writh  mental  disease  ;  for  instance,  a  patient 
may  state  that  he  cannot  possibly  swallow,  that  the  throat  is  entirely 
occluded ;  but  the  malady  is  in  the  brain  rather  than  in  the  gullet ; 
no  attempt  is  made  to  perform  the  act,  and  the  passage  of  an  oesopha- 
geal bougie  will  prove  that  the  fears  are  groundless.  These  cases 
may  be  mistaken  for  true  paralysis.  "With  great  feebleness  of  mus- 
cular power  the  will  is  unable  to  excite  muscular  action  ;  the  muscles 
of  the  pharynx  appear  to  be  paralyzed,  because  they  are  not  stimu- 
lated to  healthy  contraction,  and  hence  deglutition  cannot  be  per- 
formed. This  condition  is  very  different  from  the  disease  of  the  soft 
palate  already  referred  to  in  connection  with  labio-glosso-laryngeal 
paralysis.  The  following  interesting  case,  which  was  admitted  under 
my  care  into  Guy's  Hospital  in  July,  1856,  was  a  well-marked  in- 
stance of  functional  dysphagia  from  the  state  of  the  nervous  system. 

CASE  VI.  Dysphagia.  Mania, — A.  B —  was  an  emaciated  man,  a2t,  60,  of 
a  dingy  and  sallow  appearance,  a  gas  fitter,  who  had  resided  at  Deptfbrd. 
His  wife  stated,  that  for  several  years  he  had  suffered  from  attacks  of  extreme 


OX    DISEASES    OF    THE    (ESOPHAGUS.  63 

irritability  ;  but  that  his  only  complaint  was  of  pain  in  the  region  of  the  trans- 
verse colon.  On  the  18th  July,  he  appeared  to  lose  the  power  both  of  speak- 
ing and  swallowing,  having  previously  said,  "  that  he  did  not  know  what  was 
coming  over  him."  On  the  23d  he  was  brought  to  Guy's  Hospital ;  he  was 
then  prostrate  and  unable  to  stand,  but  could  slowly  move  his  legs  and  arms; 
his  countenance  was  not  without  intelligence,  and  he  appeared  to  understand 
questions  slightly ;  he  could  not  protrude  his  tongue,  which  remained  almost 
motionless  at  the  floor  of  the  mouth  and  was  dry  on  its  surface  ;  fluids  put  into 
the  mouth  were  retained  for  a  short  time,  and  then  ran  out  again  at  the  an- 
gles of  the  lips,  but  he  could  not  be  induced  to  attempt  to  swallow ;  placing  a 
teaspoon  at  the  back  of  the  mouth  excited  some  action  of  the  muscles  ;  the 
pupils  were  active,  the  right  was  rather  larger  than  the  left ;  the  pulse  was  56, 
and  compressible  ;  the  heart's  action  was  very  feeble ;  the  respiration  was 
normal  20  per  minute,  but  the  air  could  scarcely  be  heard  to  enter  the  chest. 
The  abdominal  muscles  were  exceedingly  rigid,  but  the  abdomen  was  not  dis- 
tended. Half  a  drop  of  croton  oil  was  placed  on  the  back  of  the  tongue,  and 
afterwards,  a  nutrient  enema  was  administered.  On  the  24th,  my  colleague, 
Mr.  Cooper  Forster,  passed  an  oesophageal  tube  into  the  stomach  without  any 
difficulty  ;  some  beef  tea  thickened  with  arrowroot  was  in  this  way  adminis- 
tered ;  the  patient  afterwards  swallowed  milk  and  beef  tea,  &c.,  with  less  diffi- 
culty, and  on  the  third  day  began  to  speak  ;  he  rapidly  improved.  His  mind, 
however,  was  not  in  a  clear  state,  for  as  soon  as  he  was  able  to  eat.  he  had 
the  idea  that  no  other  patient  in  the  ward  had  any  food.  This  case  closely 
resembles  some  of  those  found  in  lunatic  asylums  ;  but  this  patient  was  unable 
to  make  the  attempt  to  swallow  ;  a  condition  which  might  easily  have  been 
mistaken  for  paralysis  of  the  muscles  themselves.  I  have  since  learned  that 
after  leaving  the  hospital  he  became  violently  maniacal. 

A  similar  condition  of  nervous  dysphagia  is  observed  in  hysteria, 
and  occurs  in  young  women  of  an  excitable  character,  who  are  suffer- 
ing from  leucorrhoea,  or  painful  menstruation,  and  impaired  diges- 
tion. The  same  strong  language  is  used  by  these  patients  to  express 
their  inability  to  swallow,  and  they  show  the  greatest  unwillingness 
even  to  make  the  attempt.  A  young  woman  about  twenty-three 
years  of  age,  was  thus  reduced  to  the  greatest  prostration,  resembling 
a  case  of  fever.  On  passing  an  cesophageal  bougie,  no  obstruction 
whatever  was  found ;  she  afterwards  swallowed  food  in  small  quan- 
tities, which  was  increased  day  by  day  until  she  took  the  usual 
amount.  Fright,  terror,  and  cold  are  found  to  produce  spasmodic 
dysphagia,  and  we  have  seen  instances  of  this  kind  after  violent 
storms  of  thunder  and  lightning;  but  in  lesser  degrees  it  is  not  un- 
frequent  in  hysterical  subjects. 

Spasmodic  stricture  of  the  oesophagus  is  not  limited  to  women,  but 
may  come  on  suddenly  in  men,  with  a  sense  of  extreme  dysphagia, 
almost  without  apparent  cause,  and  continue  for  several  days,  so 
that  the  attempt  to  take  food  is  followed  by  extreme  pain  and  dis- 
tress, and  the  instant  rejection  of  any  portion  that  is  swallowed. 
This  spasmodic  obstruction  of  the  oesophagus  may  be  superadded  to 
partial  narrowing  of  the  tube,  and  be  almost  a  constant  condition  for 
many  years,  so  that  great  care  is  required  during  the  process  of  de- 
glutition, which  must  be  performed  slowly. 

In  an  instance  of  this  kind,  a  gentleman  found  that  if  he  swallowed 


04  ON    DISEASES    OF    THE    (ESOPHAGUS. 

slowly,  and  took  a  deep  inspiration  at  the  close  of  the  process,  the 
food  passed  the  diaphragm  into  the  stomach,  as  if  the  act  of  inspira- 
tion enlarged  the  cesophageal  opening  in  the  diaphragm. 

The  following  is  a  remarkable  instance  of  spasmodic  affection  of 
the  oesophagus. 

CASE  VII. — A  gentleman,  get.  65,  had  enjoyed  good  health  till  he  was 
thirty  years  of  age  without  any  difficulty  in  swallowing.  One  day  whilst 
taking  food  he  suddenly  felt  something  stick  in  his  throat,  and  he  believed  he 
would  be  choked.  He  became  blue  in  the  face,  and  the  dyspnoea  was  great 
and  noisy.  By  a  great  effort  he  managed  to  force  on  the  morsel  of  food  ;  but 
for  months  afterwards  he  had  the  greatest  difficulty  in  swallowing,  and  could 
only  take  the  smallest  sips.  He  improved  somewhat,  but  still  had  to  take  his 
meals  with  great  caution,  so  much  so  that  he  was  quite  unable  to  dine  even 
with  his  family,  as  he  had  to  masticate  over  and  over  again,  and  he  always 
finished  his  meal  with  the  feeling  of  thankfulness  that  one  more  was  over  with- 
out a  stoppage.  He  was  worse  at  times,  and  anything  cold  seemed  to  excite 
spasm  and  almost  prevent  deglutition  ;  warm  substances  were  more  easy  to 
swallow,  and  even  capsicum  lozenges  assisted  the  process.  He  had  never  con- 
sulted any  one,  and  his  condition,  described  almost  in  his  own  words,  was 
mentioned  accidentally  as  explaining  a  meal  of  dry  bread  with  gentian  and 
ammonia,  which  he  was  taking  by  sips. 

Spasmodic  stricture  of  the  oesophagus  is  very  irregular  in  its  recur- 
rence. 

A  patient,  set.  75,  with  degeneration  of  the  vessels  and  albuminuria,  had  a 
peculiar  condition  of  the  pharynx.  The  uvula  had  been  removed  many  years 
previously,  and  the  posterior  pillars  of  the  fauces  were  adherent  to  the  poste- 
rior part  of  the  pharynx,  so  as  almost  to  obliterate  the  opening  of  the  pos- 
terior nares.  He,  had  neither  headache  nor  cough,  neither  palpitation  nor 
dyspnosa,  but  every  three  or  four  days  suddenly  whilst  at  dinner  flatulence 
appeared  to  cause  obstruction  in  the  gullet,  then  sudden  sickness  came  on 
and  the  inability  to  swallow  ;  after  a  short  time  the  passage  became  free  and 
he  could  swallow  as  usual.  The  peculiar  condition  of  the  pharynx  in  inter- 
fering with  the  first  part  of  the  process  of  deglutition  did  not  wholly  account 
for  this  dysphagia. 

A  young  gentleman  called  upon  me  in  great  alarm,  stating  that  he 
had  obstruction  of  the  throat,  and  that  he  could  not  swallow.  With- 
out knowledge  of  the  physiology  of  deglutition  he  had  been  making 
incessant  attempts  to  swallow  during  eighty  miles  of  railway  journey, 
and  the  failure  had  only  led  to  increased  efforts,  but  of  no  avail  be- 
cause his  saliva  was  exhausted ;  a  glass  of  water  enabled  him  to 
complete  the  act,  and  assured  him  of  the  absence  of  disease. 

Abercrombie1  gives  the  case  of  a  lady,  set.  40,  in  whom  stricture 
of  the  oesophagus  was  supposed  to  exist.  The  symptoms  continued 
for  a  year,  and  were  entirely  relieved  by  passing  "an  egg-shaped 
silver  ball  attached  to  a  handle  of  silver  wire." 

This  state,  however,  is  not  limited  to  one  sex.  Mayo2  mentions 
a  remarkable  instance  of  spasmodic  stricture  of  the  oesophagus  in  a 

1  Abercrombie  on  'Diseases  of  the  Stomach.' 

2  Mayo,  'Outlines  of  Pathology.' 


OX    DISEASES    OF    THE    (ESOPHAGUS.  '65 

gentleman,  set.  60,  who  had  sudden  obstruction  of  the  oesophagus 
whilst  at  dinner.  It  was  relieved  by  the  passage  of  a  bougie.  The 
brother  of  the  patient,  who  had  suffered  from  gout,  had  had  a  similar 
seizure.  The  same  author  narrates  a  case  of  spasmodic  stricture  in 
a  young  man,  produced  by  ulceration  of  the  interior  of  the  larynx. 
It  must  be  borne  in  mind  also,  that  spasmodic  contraction  of  the 
oesophagus  tends  to  increase  the  obstruction  arising  from  organic 
causes,  so  that  the  degrees  of  dysphagia  in  the  same  case  may  vary, 
being  modified  by  this  spasmodic  complication.1 

The  general  symptoms  and  history  aid  us  in  the  diagnosis  of  these 
diseases :  thus,  there  is  an  absence  of  emaciation ;  the  attack  comes 
on  suddenly  after  a  slight  cause,  as  from  nervous  shock  or  slight 
catarrh;  there  is  freedom  from  pain,  but  nervous  excitement  is 
always  present. 

Hot  fomentations,  the  use  of  fluid  instead  of  solid  food  for  a  short 
time,  aperient  or  antispasmodic  enemata,  as  of  turpentine  or  rue, 
will  afford  relief  in  these  cases.  Tonics  are  often  of  service,  as  the 
compound  iron  mixture  with  decoction  of  aloes,  or  the  compound 
steel  pill,  with  aloes  and  myrrh;  so  also  quinine,  zinc,  valerian; 
vegetable  tonics  may  be  used;  and  the  shower  bath,  good  air  and 
exercise,  and  cheerful  occupation  of  the  mind  will  greatly  assist  in 
the  restoration  to  health. 

Bougies  are  often  employed,  but  their  use  is  not  generally  bene- 
ficial, and  may  be  detrimental  by  tending  to  perpetuate  and  aggra- 
vate a  state  of  spasmodic  irritation  and  contraction;  but  in  cases 
where  the  muscles  of  the  pharynx  have  lost  their  contractile  power, 
the  direct  introduction  of  food  is  absolutely  reqiiired.  In  some 
hysterical  patients,  the  refusal  to  swallow  arises  from  a  disordered 
will  rather  than  from  any  disease  in  the  oesophagus  itself. 

Hulke,  under  the  term  cesophagismus,2  describes  the  case  of  a  pale 
emaciated  boy,  aet.  10,  who  had  vomited  both  solid  and  fluid  food 
for  four  months  immediately  after  swallowing.  The  ejecta  were  so 
unaltered  that  it  was  thought  they  could  not  have  passed  into  the 
stomach,  and  a  probang  seemed  to  meet  with  obstruction  a  short 
distance  from  the  cardia.  Before  his  illness  he  had  been  healthy 
and  stout.  He  was  very  excitable  and  his  mother  was  hysterical;  he 
was  quite  cured  by  careful  feeding  and  moral  suasion. 

Paralysis  of  the  muscles  of  deglutition  may  be  either  functional 
or  due  to  organic  disease  of  the  nervous  centres. 

A  good  instance  of  the  functional  disease  is  found  in  diphtheritic 
paralysis  described  on  p.  48.  When  due  to  organic  disease  of  the 
brain  the  paralysis  of  the  muscles  of  deglutition  is  generally  observed 
immediately  to  precede  the  paralysis  of  the  respiratory  muscles,  and 

1  See  also  Sir  James  Paget,  '  Lancet,'  Jan.  7th,  1871.     He  considers  hysterical  or 
spasmodic  stricture  of  the  esophagus  as  the  homologue  in  the  pharynx  or  oesophagus 
of  that  want  of  harmony  hetween  the  organs  of  speech  and  respiration  which  produces 
stammering,  and  that  it  is  due  to  unruly  contraction  of  certain  fibres  of  the  oesopha- 
gus.    The  degree  of  contraction  varies"  in  different  cases,  in  some  only  compelling 
them  to  take  their  meals  apart,  in  others  bringing  about  starvation  and  requiring 
the  use  of  enemata. 

2  '  Clinical  Soc.  Trans.,'  vol.  vi,  p.  52. 

5 


66  ON    DISEASES    OF    THE    OESOPHAGUS. 

is  looked  upon,  correctly,  as  a  common  sign  of  approaching  death. 
The  nervous  centre  of  the  function  of  swallowing  is  close  to  that  of 
respiration,  and  there  is  an  intimate  connection  between  them. 
Where  there  is  loss  of  the  power  of  deglutition,  the  placing  of  fluid 
in  the  mouth  will  be  followed  by  its  entrance  into  the  larynx,  or  by 
violent  cough,  or  it  may  even  hasten  death. 

We  not  urifrequently,  however,  observe,  in  cases  of  cerebral  dis- 
ease, when  the  muscles  of  the  tongue  are  paralyzed,  that  the  swal- 
lowing, especially  of  solids,  becomes  exceedingly  difficult.  This 
difficulty  arises  from  the  movements  of  the  tongue  being  restrained, 
for  the  bolus  of  food  cannot  be  formed,  nor  pushed  back  into  the 
fauces;  fluids  are  more  easily  swallowed,  because  more  readily 
brought  within  the  action  of  the  true  muscles  of  deglutition.  Under 
such  circumstances  the  introduction  of  nourishment  by  an  elastic 
tube  has  been  the  means  of  prolonging  life;  it  is  probable  that  the 
muscular  fibres  of  the  oesophagus  have  diminished  contractile  power 
in  these  cases.  The  most  severe  instances  of  .this  condition  are  to 
be  found  in  glosso-laryngeal  disease  already  referred  to. 

Another  class  of  cases  are  those  connected  with  mental  disease, 
some  of  which  may  easily  be  mistaken  for  true  paralysis.  With 
great  feebleness  of  muscular  power,  we  may  find  that  the  will  is 
unable  to  excite  muscular  action;  that  the  muscles  of  the  pharynx 
appear  paralyzed,  because  they  are  not  stimulated  to  healthy  contrac- 
tion, and  hence  deglutition  cannot  be  performed. 

Hypertrophy  of  the  muscular  coat  requires  no  lengthened  descrip- 
tion, since  it  is  invariably  associated  with  obstruction  in  some  part 
of  the  tube ;  for  the  obstruction  is  almost  always  caused  by  stricture, 
which  leads  to  the  hypertrophy ;  but  there  is  a  case  in  the  Guy's 
Post-mortem  Records  of  a  very  much  hypertrophied  oesophagus 
where  the  only  explanation  was  a  large  heart  with  mitral  imperfec- 
tion. The  muscular  coat  was  especially  thick  opposite  the  enlarged 
heart. 

Dilatation  of  the  (Esophagus.  Pouch. — Three  forms  of  dilatation 
of  the  coats  of  the  oesophagus  and  pharynx  are  met  with  ;  in  the  1st 
the  canal  is  uniformly  dilated ;  in  the  2d  a  pouch  or  bag  is  formed, 
consisting  of  all  the  coats ;  and,  in  the  3d,  there  is  a  hernial  protru- 
sion of  the  mucous  membrane  .penetrating  through  the  muscular 
coat. 

The  first  is  found  occasionally  present  in  organic  occlusion  of  the 
oesophagus,  especially  where  it  is  of  a  non-malignant  character,  and 
of  slow  formation.  Mayo,  in  his  '  Outlines  of  Pathology,'  narrates 

a  remarkable  instance  of  oesophageal  dilatation.     "  Mary  B ,  aet. 

83,  ill  for  ten  years,  was  in  a  state  of  extreme  debility  and  emaciation ; 
the  food  was  returned  in  three  or  four  minutes  mixed  with  mucus, 
and  death  took  place  from  inanition.  The  oesophagus  from  its  junc- 
tion with  the  pharynx,  which  was  rather  less  capacious  than  usual, 
was  enlarged  to  an  extraordinary  degree  of  dilatation.  The  greatest 
width  that  it  attained  exceeded  two  and  a  half  inches  when  distended, 
and  occurred  about  four  inches  above  the  cardia.  The  tube  then 
narrowed  more  abruptly,  so  as  to  render  the  cardiac  termination  like 


ON    DISEASES    OF    THE    (ESOPHAGUS.  67 

the  pharyngeal  of  nearly  the  usual  dimension.  The  structure  of  the 
cardiac  end  for  about  an  inch,  and  that  of  the  pharyngeal  end  for 
about  an  inch  and  a  half,  was  healthy.  Intermediately  the  lining 
tunic  was  thickened  and  opaque ;  the  mucous  membrane  had  the 
appearance  of  having  yielded  or  opened  into  flat  shallow  depressions, 
which  followed  a  longitudinal  direction  above,  and  below  formed 
irregular  pits.  At  the  depressed  surfaces,  the  membrane  had  the 
natural  color;  between  them,  it  was  opaque  and  whitish.  The  mus- 
cular fibres  were  normal  in  color  and  thickness ;  they  had  grown 
with  the  expansion  of  the  canal." 

In  vol.  x  of  the  '  Pathological  Transactions'  Dr.  Barker  has  re- 
corded an  instance  of  dilatation  of  the  oesophagus  commencing  two 
inches  below  the  rima,  and  forming  an  ovoid  swelling  the  size  of  a 
swan's  egg  in  the  posterior  mediastinum.  There  was  a  strumous 
deposit  in  the  bronchial  glands  forming  masses  as  large  as  the  fist, 
and  firmly  adhering  to  the  front  of  the  oesophagus  and  of  the  trachea, 
and  connected  with  fibrous  tissue  surrounding  the  origin  of  the  great 
vessels.  There  was  also  a  perforating  ulcer  in  the  duodenum,  com- 
municating with  a  small  abscess  in  the  peritoneum. 

As  to  the  second  form,  consisting  of  a  muscular  pouch,  Mr.  C.  "W. 
Worthington,  in  vol.  xxx  of  the  "Trans,  of  the  Eoyal  Med.  and  Chir. 
Society,'  narrates  an  instance  under  his  own  care.  A  gentleman,  aet. 
60,  three  years  before  his  death,  suffered  from  slight  dysphagia,  which 
gradually  became  extreme,  with  progressive  emaciation,  and  for 
three  weeks  he  was  sustained  by  injections.  The  oesophagus  was 
constricted  at  the  commencement,  so  that  an  urethral  bougie  was 
alone  capable  of  being  passed.  Opposite  the  cricoid  cartilage,  be- 
tween the  trachea,  the  oesophagus,  and  the  cervical  vertebrae,  was  a 
pouch  three  and  a  half  inches  in  length,  like  the  finger  of  a  glove ; 
two-thirds  of  it  were  covered  by  the  muscular  fibres  of  the  constric- 
tors ;  the  opening  into  the  pouch  was  free.  The  mucous  membrane 
of  the  oesophagus  at  the  constricted  part  was  healthy.  The  same 
author  quotes  from  Sir  Charles  Bell  an  instance  of  Mr.  Ludlow's  of 
a  muscular  pouch,  between  the  oesophagus  and  vertebras,  in  a  man 
a3t.  60,  who  had  dysphagia  for  five  years;  and  also  mentions  from 
Sir  Charles  Bell  one  of  the  third  form  of  pouch,  consisting  only  ot 
mucous  membrane  protruded  through  the  muscular  layer.  This  last 
form  may  be  free  from  any  symptom.  A  case  of  this  kind  recently 
occurred'  at  Guy's  Hospital :  J.  C— ,  aet.  28,  was  brought  in  a  dying 
state  with  peritonitis  from  perforation  of  the  ileum  during  typhoid 
fever.  At  the  commencement  of  the  oesophagus  was  a  pouch  half 
an  inch  in  length,  consisting  of  the  mucous  membrane,  and  very 
slightly  covered  at  the  neck  of  the  pouch  by  a  few  muscular  bands ; 
it  was  full  of  mucus.  (Prep.  178472.) 

An  interesting  case  of  pouch-like  dilatation  of  the  lower  part  of 
the  pharynx  in  a  man.  aet.  63,  who  had  suffered  from  dysphagia  for 
many  years,  is  recorded  in  the  'Path.  Soc.  Trans.,'  vol.  xvii,  p.  Ml. 
The  upper  part  of  the  pharynx  was  enlarged,  with  the  muscles  hy- 
pertrophied.  At  the  lower  border  of  the  inferior  constrictor  of  the 


68  ON    DISEASES    OF    THE    (ESOPHAGUS. 

pharynx  was  a  pouch  of  mucous  membrane,  the  size  of  a  bantam's 
egg,  projecting  downwards  behind  the  oesophagus. 

Some  of  these  oesophageal  pouches  are  probably  of  congenital  ori- 
gin ;  two  interesting  cases  of  congenital  defect  were  brought  before 
the  Pathological  Society  by  Dr.  Herbert  Ilott,  and  are  published  in 
the  '  Transactions'  for  1876.  The  oesophagus  terminated  in  a  thick 
pouch  on  the  posterior  surface  of  the  trachea,  a  little  below  the  cri- 
coid  cartilage,  and  a  probe  could  be  passed  from  the  stomach  upwards 
through  the  terminal  portion  of  the  oesophagus  into  the  trachea,  and 
it  is  this  state  that  is  usually  observed  in  malformation  of  the  oeso- 
phagus. 

III.  Organic  obstruction  of  the  oesophagus  arises  from  conditions 
which  may  be  internal  in  their  character  or  they  may  be  produced 
by  external  pressure.  The  former,  internal,  may  be  from  annular 
constriction,  from  syphilis,  from  ulceration  and  cicatrices,  and  from 
cancerous  disease. 

External  obstruction  arises  from  pressure  of  aneurismal  or  medias- 
tinal  tumors,  from  disease  of  glands,  from  effusions  into  the  pleura 
and  pericardium,  and  from  inflammation  in  the  mediastinum  and  ab- 
normal arrangement  of  the  vessels. 

The  history  of  the  symptoms  will  alone  enable  us  to  distinguish 
these  cases  from  each  other.  In  some  of  them,  we  may  hope  that 
remedial  means  may  be  successfully  used  which  have  hitherto  scarcely 
been  fairly  tried;  in  other  cases,  it  is  evident  that  nothing  can  be 
done  for  cure,  but  the  pain  and  the  severity  of  the  symptoms  may  be 
mitigated. 

Annular  constriction  of  the  oesophagus  consists  in  the  formation  of 
inflammatory  material  in  the  submucous  cellular  tissue ;  the  new 
tissue  contracts,  and  becomes  exceedingly  dense,  forming  a  firm  con- 
stricting band,  whilst  the  tube  above  dilates,  and  this  obstruction 
increasing,  at  last  the  passage  of  food  becomes  impossible. 

The  cause  of  simple  contraction  of  the  oesophagus  is  very  obscure ; 
it  generally  occurs  towards  the  lower  part,  and  sometimes  the  history 
shows  that  dysphagia  had  been  present  in  early  life.1  Sir  Everard 
Home2  also  refers  to  instances  in  which  difficult  deglutition  has  been 
present  from  infancy,  or,  as  in  a  case  recorded  by  Dr.  Fagge3  only 
from  middle  life. 

The  oesophagus  is  developed  by  the  formation  of  a  groove  in  the 
layers  of  the  germinal  membrane,  and  this  groove  is  subsequently 
converted  into  a  tube.  Interference  with  the  process  of  develop- 
ment may  lead  to  irregularities  in  the  size  of  the  tube  and  occasion- 
ally also  to  its  complete  obliteration,  and  in  this  way  some  cases  of 
simple  narrowing  of  the  oesophagus  may  be  explained,  as  well  as 
those  instances  of  rare  occurrence  in  which  the  canal  ends  in  a  blind 
extremity.4 

1  'Path.  Soc.  Trans.,'  vol.  xvii,  p.  138. 

2  '  Practical  Observations  on  the  Treatment  of  Stricture  in  the  Urethra  ami  in  the 
(Esophagus.' 

3  'Guy's  Hospital  Reports,'  3  ser.,  vol.  xvii,  p.  413. 
«  Porro,  'Syd.  Soc.  Bien.  Retr.,'  1871-2,  p.  152. 


ON    DISEASES    OP    THE    03SOPHAGUS.  69 

In  reference  to  congenital  defect,  we  may  mention  that  an  obstruc- 
tion sometimes  exists  at  the  upper  part,  and  is  due  to  a  membranous 
fold  across  the  canal  ;*  but  this  is  easily  explicable  when  we  remem- 
ber that  the  pharynx  is  formed  separately  from  tie  oesophagus,  and 
afterwards  opens  into  it.  Any  failure  of  perfect  obliteration  of  the 
intervening  septum  will  lead  to  the  condition  referred  to,  and  in  a 
similar  manner,  but  more  frequently,  malformation  is  observed  in 
the  rectum,  which  being  developed  on  the  same  plan  remains  as  a 
blind  pouch.2 

AHien  the  dysphagia  has  not  appeared  till  late  in  life  the  con- 
striction may  still  have  been  due  to  congenital  defect,  the  compensa- 
ting hypertrophy  of  the  muscular  coats  having  for  a  time  overcome 
the  impediment.  At  length,  failing  to  do  so,  or  ordinary  senile 
changes  leading  to  the  degeneration  of  the  muscular  fibre,  dilatation 
of  the  canal  and  obstruction  ensue. 

Syphilitic  stricture  of  the  oesophagus  is  not  a  common  disease,  and 
the  pathological  evidence  of  the  existence  of  such  a  condition  is  still 
imperfect.  In  the  '  Dublin  Quarterly  Journal  of  Medical  Science,'  of 
February,  1860,  Mr.  J.  West  described  two  cases  of  dysphagia  occur- 
ing  in  young  girls  where  the  symptoms  gradually  increased,  and  at 
length  led  to  a  fatal  result ;  four  inches  down  the  oesophagus  there 
was  a  constriction  arising  from  the  formation  of  fibrous  material  in 
the  submucous  tissue.  Disorganization  of  the  lungs  had  taken  place. 
Mr.  .West  believed  that  the  disease  in  each  case  was  of  syphilitic 
origin.  The  same  author  makes  a  further  contribution  on  the  same 
subject,  in  the  'Lancet'  for  1872,3  supporting  his  previous  views  and 
quoting  from  various  authors.  Reference  to  the  post-mortem  records 
at  Guy's  Hospital  gives  three  cases  which  were  probably  of  a  syphi- 
litic character. 

The  first  case  was  a  woman,  aet.  32,  in  whom  a  firm  stricture  was 
located  at  the  termination  of  the  pharynx ;  the  second  case  was  a 
woman,  eet.  43,  pregnant  at  the  time  of  her  death.  Around  the 
pharynx  opposite  the  mucous  folds  of  the  glottis  were  irregular 
excavated  ulcers  with  thick  margins. 

The  third  case  I  give  in  more  detail. 

CASE  VIII A  man  aet.  48,  who  was  under  my  care  in  Guy's,  had  been 

a  tobacco-cutter  by  trade,  and  when  seventeen  years  of  age  had  rheumatic 
fever.  When  twenty-seven  he  had  syphilis  ;  he  had  been  intemperate  in  his 
habits.  His  illness  commenced  four  months  before  admission  into  the  hospital, 
and  it  was  attributed  to  cold.  He  experienced  soreness  of  the  throat,  which 
gradually  became  more  severe  and  was  accompanied  with  difficulty  in 
swallowing.  The  dysphagia  soon  became  so  extreme  that  he  could  only 
swallow  a  small  quantity  of  fluid  food.  Two  months  later  he  became  affected 

1  Crisp,  'Path.  Soc.  Trans.,'  vol.  xxiii,  p.  128. 

2  For  some  further  information  on  this  point  and  on  that  of  oesophageal  fistulse,  their 
origination  in  permanent  conditions  of  the  brachial  clefts  and  the  likelihood  of  the  ex- 
istence of  a  communication  between  the  trachea  and  the  oesophagus  in  such  cases, 
the  reader  is  referred  to  the  '  Surgical  Diseases  of  Childhood'  by  Mr.  Holmes. 

3  "On  Syphilitic  Constriction  of  the  (Esophagus  and  Pharynx,"  'Lancet,'  August 
1st,  1872. 


70  OX    DISEASES    OF   THE    (ESOPHAGUS. 

with  severe  pain  on  the  right  side  of  the  neck  ;  the  pain  passed  upwards  in 
the  course  of  the  lesser  occipital  nerve,  cough  also  came  on.  He  was  pale 
and  had  a  cachectic  appearance,  and  emaciated  rapidly.  His  voice  was  weak, 
but  not  hoarse.  Thfcre  was  an  enlarged  rery  hard  gland,  situated  beneath 
the  right  sterno-mastoid  muscle;  other  smaller  glands  could  also  be  felt. 
The  breath  was  offensive  and  the  tongue  furred.  When  deglutition  was 
attempted  he  experienced  gieat  pain,  and  only  a  very  small  quantity  of  food 
passed  down  the  oesophagus,  and  very  frequently  it  was  forcibly  ejected 
through  the  nares.  There  was  no  stridulous  respiration,  but  the  throat  was 
too  sensitive  to  permit  an  examination  to  be  made  with  the  laryngoscope. 
When  the  finger  was  introduced  as  far  as  the  pharynx  the  epiglottis  was 
found  to  be  free  from  disease,  but  beyond  it  at  the  posterior  and  lower  part  of 
the  pharynx  a  raised  and  hard  swelling  could  be  felt ;  this  was  at  the  com- 
mencement of  the  oesophagus  opposite  to  the  cricoid  cartilage.  There  was 
dulness  at  the  apex  of  the  lung  on  the  right  side,  with  bronchial  breathing 
and  bronchophony.  He  was  unable  to  take  cod-liver  oil,  but  the  avoidance 
of  solid  food  afforded  some  relief.  The  dysphagia  again  increased,  but  was 
relieved  by  the  use  of  nutrient  injections,  thus  allowing  the  throat  to  rest. 
These  injections  were  after  a  short  time  quite  ineffective,  and  as  the  distress 
and  emaciation  became  extreme,  gastrotomy  was  proposed.  The  patient 
suffered  from  pain  in  the  course  of  the  descending  branches  of  the  cervical 
nerves  from  the  pressure  of  the  enlarged  glands  in  the  neck.  It  was  felt  that 
unless  some  relief  was  speedily  afforded  the  patient  would  rapidly  sink,  and 
on  the  24th  Mr.  Bryant  proceeded  to  open  the  stomach.  For  twenty-four 
hours  the  stomach  was  allowed  to  rest  and  nutrient  injections  were  given  by 
the  rectum  ;  food  in  small  quantity  was  then  introduced  into  the  stomach. 
The  patient  was  free  from  pain,  and  said  that  he  felt  better  for  the  food.  On 
the  28th  he  became  very  prostrate  and  occasionally  delirious  ;  food  introduced 
by  the  opening  into  the  stomach  flowed  out,  but  nutrient  injections  were  con- 
tinued into  the  rectum  as  long  as  they  could  be  borne.  He  died  on  the  .'Sotli, 
5^  days  or  130  hours  after  the  operation.  On  inspection,  ten  hours  after 
death,  the  wound  in  the  parietes  was  perfectly  united  to  the  stomach,  and 
there  was  no  peritonitis ;  the  serous  membranes  had  become  adherent.  At 
the  commencement  of  the  oesophagus  and  the  termination  of  the  pharynx  was 
an  oval  ulcer  about  two  inches  in  length  ;  it  was  hard  and  its  edges  were 
slightly  raised  and  puckered ;  its  surface  was  granular,  and  it  had  extended 
forwards  to  the  larynx,  leaving,  however,  a  strip  of  healthy  mucous  mem- 
brane. In  the  larynx  on  the  left  side  was  a  small  ulcer  one-eighth  of  an 
inch  in  diameter  .on  a  raised  base,  and  the  thickening  extended  to  the  poste- 
rior part  of  the  left  vocal  cord.  There  were  several  glands  in  the  neck  filled 
with  yellow  low  organized  deposit.  The  right  pleura  was  adherent  at  the 
upper  part,  and  at  the  apex  of  the  lung  was  a  small  irregular  cavity  bounded 
by  dense  iron-gray  deposit.  The  whole  of  the  lower  lobe  of  the  right  lung 
was  acutely  diseased,  consolidated,  and  in  a  state  of  red  and  gray  hcpatiza- 
tion.  The  left  lung  contained  some  softening  patches  of  pneumonia,  resem- 
bling pytemic  inflammation.  The  heart  was  atrophied ;  the  kidneys  were 
small,  but  healthy ;  the  colon  contained  fecal  matter  in  its  whole  length,  but 
the  small  intestine  was  contracted. 

The  following  instance  was  probably  due  to  syphilitic  disease;  the 
very  gradual  onset,  thfc  long  duration,  the  partial  recovery  under 
anti-syphilitic  remedies,  tended  to  support  this  opinion. 

CASE  IX A  lady,  aet.  40,  for  many  years  had  suffered  from  water-brash, 

and  for  six  or  seven  years  before  death  had  had  pain  in  the  oesophagus  on 


ON    DISEASES    OF    THE    (ESOPHAGUS.  71 

swallowing.  She  stated  that  the  food  appeared  to  stop  at  the  centre  of  the 
(esophagus ;  for  two  years  she  had  suffered  from  the  excessive  discharge  of 
mucus  and  saliva,  with  thirst.  These  symptoms  and  the  dysphagia  were 
relieved  by  the  use  of  myrrh  and  aloes;  the  dysphagia,  however,  increased, 
and  a  year  before  her  death  she  was  unable  to  swallow  any  solid  food.  In 
May,  1874,  she  vomited  an  elongated  clot  the  size  of  the  finger.  In  July 
dysphagia  increased  in  severity,  but  her  principal  complaint  was  of  flatulence 
and  the  discharge  of  mucus.  The  mucous  membrane  of  the  throat  was  granu- 
lar, the  abdomen  was  contracted,  and  there  was  no  pain  at  the  region  of  the 
stomach.  Mr.  Durham  passed  a  bougie  nearly  into  the  stomach  on  July 
13th,  and  a  few  days  later  a  smaller  one  into  the  stomach.  The  size  of  the 
bougie  was  increased,  and  soon  afterwards  the  patient  could  swallow  much 
more  easily.  There  was  a  suspicion,  from  the  fact  of  her  having  had  mis- 
carriages and  no  living  children,  that  the  disease  might  be  syphilitic  in  char- 
acter, and  perchloride  of  mercury  with  iodide  of  potassium  were  given.  The 
relief  was  considerable,  and  for  several  months  she  was  in  comfortable  health. 
During  the  spring  of  the  following  year  the  dysphagia  returned,  with  the  same 
complaint  of  mucous  secretion.  She  was  urged  to  allow  the  former  treatment 
to  be  followed,  but  it  was  postponed  till  the  June  of  1875,  when  exhaustion 
had  become  extreme,  and  she  sank  at  the  beginning  of  July.  No  inspection 
was  made. 

The  relief  that  was  afforded  by  perchloride  of  mercury  and  iodide 
of  potassium,  and  the  introduction  of  the  bougie,  as  well  as  the  very 
gradual  onset  of  the  complaint,  led  us  to  suspect  syphilitic  disease 
as  the  cause  of  the  obstruction ;  and,  it  is  to  be  regretted,  that  the 
same  plan  of  treatment  was  not  pursued  when  the  symptoms  re- 
turned. 

Three  other  cases  of  simple  stricture  are  recorded  in  the  'Patholo- 
logical  Society's  Transactions,'  the  ages  of  each  being  respectively 
fifty-five,  fifty  four,  and  forty-four.  In  these  cases,  two  males  and 
one  female,  tlie  disease  was  in  the  middle  or  in  the  lower  part  of  the 
tube.  Dr.  Moxon  mentions,  that  he  has  once  met  with  syphilitic 
gummata  in  the  oesophagus.  It  is,  however,  probable  that  many 
instances  of  syphilitic  obstruction  occur  which  are  cured  by  the  use 
of  perchloride  of  mercury  and  iodide  of  potassium;  for  it  is  well 
known  that  these  diseases  affecting  the  pharynx  as  well  as  the 
larynx,  rapidly  improve  under  treatment.  Bougies  may  be  of  great 
service  in  restoring  the  calibre  of  the  canal,  but  great  care  must  be 
employed  in  their  introduction;  for  disastrous  consequences  have 
followed  their  injudicious  use  in  cases  of  ulceration. 

Whilst  referring  to  syphilitic  disease  we  may  mention  a  specimen 
in  the  Hunterian  Museum  of  the  Koyal  College  of  Surgeons,  in  which 
a  gummatous  tumor  in  the  liver  had  pressed  upon  the  oesophagus, 
and  had  caused  obstruction. 

Another  form  of  organic  stricture  is  from  the  contraction  of  cica- 
trices; some  of  these  cases  may  be  from  old  syphilitic  disease,  or  they 
may  result  from  ulceration  originating  in  other  causes,  as  disease  of 
the  bronchial  glands.  The  most  frequent  cause  is  the  contraction 
consequent  upon  the  action  of  corrosive  poisons  or  hot  liquids  in 
early  life.  Of  thirty -five  cases  of  stricture  of  the  oesophagus  met 


72  ON    DISEASES    OF    THE    (ESOPHAGUS. 

with  by  Keller1  in  five  years,  all  were  traced  to  the  action  of  caustic 
potash.  A  case  of  cicatrix  in  the  oesophagus  was  under  my  care 
some  time  ago  in  a  man,  set.  62.  He  had  had  some  oedema  of  the 
arms,  as  if  from  venous  obstruction.  A  cicatrix  of  an  ulcer  w;is 
found  in  the  upper  part  of  the  oesophagus.  Its  surface  was  hard 
and  puckered,  and  tough  fibrous  tissue  was  observed  on  the  outer 
side.  These  cases,  like  the  instances  of  congenital  stenosis  already 
recorded,  survive  for  a  considerable  period.  An  instance  is  men- 
tioned in  the  'Lancet'  of  a  gentleman  who  had  swallowed  sulphuric 
acid  when  two  years  of  age,  and  for  thirty  years  did  not  require  any 
treatment.  We  shall  again  have  to  refer  to  these  cases  in  speaking 
of  the  action  of  poisons. 

In  recorded  cases  of  annular  stricture,  the  obstruction  has  gradu- 
ally increased  in  severity,  and  unless  we  have  a  history  of  poison 
having  been  taken,  or  of  the  discharge  of  pus  from  an  abscess,  we 
know  of  no  direct  symptom  by  which  this  form  of  obstruction  can 
be  distinguished  from  that  arising  from  cancerous  disease.  The 
passage  of  a  bougie  may  reveal  to  us  the  presence  and  position  of 
the  obstruction  without  indicating  its  true  character,  but  the  mucus 
from  the  bougie  should  be  examined,  and  this  may  sometimes  guide 
to  a  correct  diagnosis.  A  further  means  of  diagnosis  and  also  of 
treatment  has  lately  been  advocated  in  auscultation  of  the  oesopha- 
gus by  Dr.  Hamburger  ('Wien  Med.  Jahrb.,'  xv,  2)  and  Dr.  Clifford 
Allbutt  ('Brit.  Med.  Journal,'  Oct.,  1875);  others  have  also  confirmed 
the  value  of  the  suggestion,  and  I  have  no  doubt  that  the  passage  of 
fluid  may  be  heard  passing  down  the  tube  and  impinging  against  a 
definite  obstruction. 

In  Cancerous  Diseases  of  the  (Esophagus  and  Pharynx  the  symp- 
toms are  very  similar  to  those  mentioned  as  occurring  in  ulceration 
of  the  oesophagus ;  the  patients  are  generally  beyond  the  middle 
period  of  life,  but  it  occurs  at  an  earlier  period- in  women  than  in  men, 
and  difficulty  in  swallowing,  which  gradually  increases  in  severity, 
is  the  most  prominent  symptom.  In  some  instances,  however,  the 
dysphagia  does  not  become  extreme  till  the  extension  of  the  cancer- 
ous ulceratiou  to  the  lungs,  or  to  other  structures,  leads  to  symptoms 
which  almost  mask  the  original  disease  ;  vomiting,  or  rather  regurgi- 
tation  of  the  food,  is  always  present  in  a  greater  or  less  degree.  The 
commencement  of  the  disease  is  often  very  insidious,  and  attributed 
to  indigestion;  flatulence  may  be  complained  of,  and  this  is  often  re- 
garded by  the  patient  as  the  cause  of  the  food  not  reaching  the  stom- 
ach. There  is  also  pain  at  the  sternum,  in  the  back,  and  sometimes 
in  the  upper  part  of  the  throat,  of  a  dull  or  burning  character ;  but 
its  intensity  varies  greatly.  The  obstruction  of  the  canal  leads  to 
the  regurgitation  of  the  saliva,  and  as  this  fluid  accumulates  it  at 
length  reaches  the  epiglottis  and  cough  is  then  produced ;  patients 
often  complain  of  these  symptoms  as  their  sole  malady,  and  also  of 

1  This  author  states  that  most  of  these  cases  were  in  children  from  two  to  four 
years  of  age  ;  23  were  cured,  3  improved,  4  remained  under  treatment,  5  died.  They 
were  treated  by  bougies,  and  the  duration  of  the  treatment  was  from  three  months  to 
one  year  and  a  half.  Keller,  '  Schmidt's  Jahrbuch.,'  vol.  118,  p.  35. 


OX    DISEASES    OF    THE    (ESOPHAGUS.  73 

flatus  regurgitated  from  the  stomach.  Dyspnoea  comes  on  when  the 
trachea  or  bronchi  are  involved,  and  is  occasionally  associated  with 
loss  of  voice,  especially  in  those  cases  in  which  the  disease  is  situated 
at  the  base  of  the  pharynx,  when  it  extends  into  the  larynx.  The 
dysphagia  and  emaciation  increase,  and  after  six  or  seven  months  the 
disease  generally  proves  fatal. 

In  organic  obstruction  of  the  oesophagus,  and  especially  in  that  of 
a  cancerous  kind  the  dysphagia  is  very  peculiar ;  the  patient  hesi- 
tates in  making  the  attempt  to  swallow,  he  takes  a  considerable  time, 
as  it  were,  to  prepare  the  muscles  of  the  pharynx  for  the  effort,  and 
when  the  attempt  is  made,  the  food  or  fluid  is  at  once  rejected :  and 
sometimes  severe  suffocative  cough  is  produced. 

Mr.  Travers1  thus  describes  cancerous  disease  of  the  pharynx  and 
oesophagus:  "  Scirrhous  strictures  followed  by  ulceration  and  cancer- 
ous fungus  are  met  with  in  the  pharynx  and  the  top  of  the  oesopha- 
gus in  elderly  persons,  chiefly  females,  in  rny  experience.  They  are 
productive  of  constant  nausea,  dry  burning  sensation  in  the  throat 
and  stomach;  difficult  breathing,  frequent  spasms,  and  alarms  of  suf- 
focation, and  excessively  impeded  deglutition;  upon  the  gentlest  in- 
troduction of  the  finger  or  bougie,  hemorrhage  follows,  which  after- 
wards becomes  spontaneous.  The  patient  has  a  faded  sallow  coun- 
tenance, a  disturbed  circulation,  and  is  emaciated  to  a  skeleton." 

Haematemesis  is  sometimes  a  symptom  of  cancer  of  the  oesophagus. 
Dr.  Bristowe  exhibited  at  the  Pathological  Society  a  specimen  of 
ulceration  of  the  oesophagus,  extending  into  enlarged  veins,  and  caus- 
ing fatal  hemorrhage  ;  and  in  another  instance  recorded  by  him,  the 
superior  intercostal  artery  was  opened  by  cancerous  ulceration.  The 
hemorrhage  produced  by  the  extension  of  cancerous  ulceration  is 
occasionally  repeated  several  times  in  the  progress  of  the  disease,  it 
indicates  its  progressive  character,  and  is  often  the  precursor  of  a 
fatal  result.  Dr.  Balding,  at  the  same  Society  in  1857,  showed  an 
ulcer  of  the  oesophagus  of  doubtfully  cancerous  character,  in  which 
a  sloughing  cavity  connected  with  the  oesophagus  had  also  formed  a 
communication  with  the  right  subclavian  artery.  The  walls  of  the 
aorta  are  often  partially  injured,  and  in  some  cases  perforated,  thereby 
leading  to  sudden  and  fatal  hemorrhage. 

Sometimes  the  lymphatic  glands  are  enlarged  in  the  neighborhood 
of  the  cancerous  mischief,  and  it  is  well  always  to  examine  the  neck 
and  axilla  for  evidence  of  glandular  disease.  Pressure  on  the  bronchi 
from  similar  enlargement  leads  to  greater  distinctness  of  respiration  in 
one  lung  than  in  the  other;  this,  however,  is  also  a  sign  of  aneurismal, 
or,  in  fact,  of  any  kind  of  tumor  exerting  direct  pressure  on  adjoining 
structures,  and  is  only  of  corroborative  value. 

In  cancerous  obstruction  of  the  oesophagus  we  do  not  generally 
find  much  distension  of  the  canal  above  the  seat  of  the  disease ;  for 
the  ulcerated  surface  leads  to  excessive  irritability,  and  food  is  very 
quickly  regurgitated ;  or  a  state  of  spasmodic  contraction  equally 
favors 'the  instantaneous  rejection  of  ingesta.  Dr.  Alderson,  however, 

i  '  Med.  Chir.  Trans.,'  vol.  xv,  p.  252. 


74  ON    DISEASES    OF    THE    (ESOPHAGUS. 

in  writing  on  Carcinoma  of  the  (Esophagus,  mentions  that  "imme- 
diately after  deglutition,  there  is  a  remarkable  bulging  out  or  pro- 
trusion of  the  oesophagus  above  the  strictured  point ;  it  is,  in  fact,  a 
bag  or  pouch,  which  is  formed  by  the  effort  of  the  patient  to  swallow 
a  larger  quantity  of  food  than  the  oesophagus,  in  its  natural  state, 
can  contain."  In  annular  obstruction  of  a  non-cancerous  nature,  the 
canal  becomes  more  enlarged  and  dilated ;  the  disease'  is  of  a  more 
chronic  character,  and  there  is  less  sensibility  of  the  surface  than  in 
true  cancer.  Monro1  mentions  an  instance  in  which  as  much  ;is  ;i 
pint  of  fluid  could  be  retained  for  ten  minutes.  This  general  dilata- 
tion of  the  oesophagus  above  an  obstruction  must  be  distinguished 
from  pouches  connected  with  the  canal,  and  already  mentioned. 

Epithelial  cancer  is  the  most  frequent  form  of  disease,  but  medul- 
lary and  scirrhous  cancer  also  occur,  the  latter  being  the  more  rare 
of  the  two;  adenoid  tumors  are  also  observed.  In  numerous  in- 
stances, the  growth  has  presented  modifications  of  epithelial  scales ; 
some  cells  had  very  large  nuclei,  other  growths  showed  large  nuclei 
thickly  set  together,  or  brood  cells.  Papillae  are  sometimes  observed 
on  the  surface  of  the  growth,  covered  by  healthy  squamous  epithe- 
lium, and  containing  capillaries  filled  with  blood  or  leucocytes. 
Other  papillae  closely  resemble  brood  cells,  their  central  portion  con- 
taining nuclei  and  nucleated  cells,  and  surrounded  by  flattened  scales 
or  cells  resembling  epithelium.  It  appears  probable,  that  in  some 
cases  degeneration  of  papillse  may  lead  to  the  formation  of  these 
clusters  of  cells,  rather  than  endogenous  growth  or  other  methods. 
The  disease  generally  extends  by  mere  contiguity  of  structure,  in- 
volving the  adjoining  bronchial  glands  at  the  root  of  the  lungs,  and 
thereby  encroaching  upon  the  bronchi :  pneumonia  is  thus  frequently 
set  up,  and  if  sloughing  occur  gangrene  of  the  lung  follows.  I  have 
several  times  found  the  pneumo-gastric  nerves  destroyed  on  one  or 
both  sides ;  and  this  destruction  of  nerve  supply  induces  congestion 
of  the  lungs,  which  is  followed  by  pneumonia,  without  actual  exten- 
sion of  disease  into  the  lung  passages. 

The  glands  and  other  viscera  are  less  commonly  implicated  in 
epithelial  cancer,  although  cases  occur  in  which  cancerous  elements 
are  discovered  in  other  structures  besides  that  primarily  affected,  as 
in  the  liver,  pancreas,  stomach,  suprarenal  capsules,  &c.  In  the  liver, 
lungs,  and  pancreas,  cells  of  an  epithelial  character,  and  precisely 
similar  to  those  found  in  the  ulcerated  oesophagus,  have  been  ob- 
served. In  the  lungs  cancerous  tubercles  may  exist  with  pneumonic 
deposit.  Mr.  H.  Gray  records  a  case  of  villous  and  epithelial  cancer 
at  the  termination  of  the  pharynx,  in  the  '  Pathological  Transactions' 
of  1855  ;  and  at  the  termination  of  the  oesophagus  colloid  cancer  has 
been  observed. 

Sometimes  the  cancerous  ulceration  extends  through  the  dia- 
phragm after  destroying  the  oesophagus.  In  a  case  of  this  kind  a 
large  sloughing  cavity  was  formed,  bounded  by  the  pancreas,  spleen, 
and  diaphragm,  and  it  communicated  with  the  posterior  mediastinum 

1  Monro  'On  Morbid  Anatomy  of  the  Gullet,  Stomach,  and  Intestine.' 


ON    DISEASES    OP    THE    (ESOPHAGUS. 


75 


by  an  opening  in  the  diaphragm.  Immediately  behind  the  pericar- 
dium was  a  large  sloughing  cavity,  presenting  above  the  truncated 
.oesophagus  and  pneumogastric  nerves,  and  terminating  below  as  just 
described.  It  was  surprising  that  the  patient  could  have  lived  as 
long  as  he  did,  but  only  three  days  before  death  he  took  a  railway 
journey,  and  was  not  at  all  aware  of  his  perilous  condition.  In 
another  case  there  was  a  remarkable  absence  of  pain,  although  food 
was  liable  to  be  at  once  rejected. 

Mondie"re,  in  '  Arch.  Ge*n.  de  He'd.,'  torn,  xxx,  mentions  from 
Keppelhont  a  case  in  which  ulceration  of  the  cardia  aud  oesophagus 
communicated  with  an  abscess  of  the  liver;  and  also  from  Dr. 
Anesaut,  an  instance  of  scirrhous  ulceration  of  the  inferior  part  of 
the  oesophagus,  rendered  fatal  by  extension  to  the  spinal  cord. 

The  fatal  issue  arises  from  several  causes,  but  these  may  generally 
be  arranged  into  two  divisions.  1st.  Inanition,  the  dysphagia  having 
become  complete ;  and  2dly,  from  the  extension  of  the  disease  to  the 
lung  or  the  surrounding  tissues.  The  character  of  the  disease  of  the 
lung  deserves  our  especial  attention.  In  only  12  instances  out  of  59 
did  death  result  from  simple  inanition,  and  even  in  these  the  lungs 
were  not  altogether  free  from  disease.  In  these  cases  the  wasting 
may  produce  mental  disturbance  or  even  delirium. 

The  mind  is  sometimes  found  to  wander  in  consequence  of  the  im- 
perfect supply  of  nourishment  to  the  brain,  or  septic  changes  take 
place,  and  the  blood  is  thereby  rendered  impure ;  again,  inflammation 
of  the  lung  may  prevent  the  arterialization  of  the  blood,  and  hence 
the  cerebral  symptoms. 


Pneumonia  was  found  in 

Gangrene  of  the  lung  in 

Pleurisy  in 

Secondary  cancer  of  other  viscera 

Inanition 

Hemorrhage     . 

Local  suppuration  round  growth 


20  cases. 
11 

1 

10 
12 

2 

3 

59 


As  to  the  causes  of  the  pneumonia,— 1st.  The  pressure  upon  or 
destruction  of  the  pneumogastric  is  followed  by  acute  pneumonia  on 
the  same  side,  or  by  gangrene ;  as  we  observed  in  several  cases  men- 
tioned in  the  annexed  table.  2d.  The  pneumonia  appears  to  result 
from  the  extension  of  disease  into  the  bronchi,  setting  up,  if  not 
pneumonia,  acute  bronchitis  or  laryngitis.  3d.  The  sloughing  of  the 
cancer  is  followed  by  septic  changes  in  the  blood,  and  consequent  in- 
flammation of  the  lungs.  4th.  Cancerous  growth  or  tubercles  in  the 
lung  acts  as  the  cause  of  congestion  and  inflammation.  5th.  Stru- 
mous  disease  of  the  lung  may  already  exist. 


76 


ON    DISEASES    OF    THE    (ESOPHAGUS. 


Table  of  Cases  of  Cancer  of  (Esophagus  and  Pharynx. 


No. 

Sex. 

Age. 

Seat. 

1 

M. 

45 

Upper  part  to  root  of  lung 

2 

M. 

50 

An  inch  from  trachoal  bifur- 

cation 

3 

M. 

73 

Opposite  root  of  lung 

4 

F. 

63 

Whole  length  of  tube 

5 

F. 

32 

Commencement 

6 

F. 

38 

At  bifurcation  of  trachea 

7 

F. 

54 

At  bifurcation 

8 

M. 

45 

Ditto 

9 

M. 

66 

Upper  part  ? 

10 

M. 

49 

Two  inches  above  bifurcation 

of  trachea 

11 

M. 

57 

Cardiac  end 

12 

M. 

64 

Bifurcation  of  trachea 

13 

M. 

71 

An  inch  above  bifurcation 

14 

M. 

63 

At  centre 

15 

F. 

31 

Pharynx  and  palate 

16 

M. 

50 

From   commencement   to  bi- 

furcation of  trachea 

17 

M. 

53 

From  three  inches  down,  to 

cardia 

18 

M. 

45 

Root  of  lung 

19 

M. 

69 

From  cricoid  to  root  of  lung 

20 

M. 

47 

Above  the  root,  behind  ma- 

nubrium 

21 

F. 

60 

Centre 

22 

M. 

68 

Pharynx 

23 

M. 

45 

Ditto 

24 

M. 

49 

Ditto 

25 

F. 

30 

Ditto 

26 

F. 

57 

Ditto 

27 

F. 

35 

Upper  oesophagus 

28 

F. 

60 

Ditto 

29 

F. 



Ditto 

30 

M. 

71 

From      cricoid      downwards 

three  inches 

31 

F. 

43 

Upper  oesophagus 

32 

M. 

52 

Ditto 

33 

M. 

39 

Ditto 

34 

M. 

48 

Ditto 

35 

F. 

35 

Upper      oesophagus,      three 

inches 

36 

M. 

— 

Long  stricture  from  cricoid 

Complications. 


Sloughing    pneumonia ; 
involved. 


pneumogastric 


Communication  with  trachea ;  pneumo- 
nia ;  granular  kidneys. 

Gangrene  of  lung  ;  cancer  of  thyroid  and 
cervical  glands. 

Cancer  of  stomach,  liver,  pancreas,  and 
lung  ;  chronic  pneumoTiia  ;  destruction 
of  the  pneumogastric  nerve  :  disease  of 
semilunar  ganglion  ;  granular  kidneys. 

Laryngitis  ;  death  from  apncea. 

Trachea  opened  ;  cancer  of  lung  and 
kidney. 

Inanition. 

Gangrene  of  lung. 

Acute  pleurisy  ;  granular  kidneys. 

Trachea  perforated  ;  gangrene  of  lung. 

Gangrene  of  lung. 

Trachea  opened  ;  pleuro-pneumonia. 

Pneumonia;  pneumogastric  nerve  in- 
volved. 

Pneumonia  ;  pneumogas tries  involved  ; 
pericardium  opened. 

Struinous  (caseous)  pneumonia. 

Pneumonia ;  pneumogastric  nerve  in- 
volved. 

Left  bronchus  opened ;  pneumogastric  in- 
volved ;  extension  of  disease  through 
the  diaphragm. 

Pneumogastric  nerves  truncated  ;  slough- 
ing extending  into  the  lung  and  through 
the  diaphragm. 

Acute  and  chronic  pneumonia  ;  pneumo- 
jastrics  free. 

Inanition ;  slight  lobular  pneumonia ; 
gastrotomy. 

Perforation  of  the  aorta ;  fatal  hemor- 
rhage. 

Sloughing  lung.      ^ 

Pneumonia. 

Hemorrhage ;  dyspnoea. 

Sloughing  lung ;  tracheotomy. 

Local  suppuration. 

Local  suppuration  ;  sudden  death. 

Inanition ;  lobular  pneumonia. 

Secondary  cancer  of  the  bones. 

Lobular  pneumonia  ;  perforation  of  %tra- 
chea. 

Pneumonia. 

Inanition  ;  gastrotomy. 

Gangrene  of  lung  ;  secondary  cancer  of 
serous  membranes. 

Perforation  of  trachea ;  broncho-pneu- 
monia ;  cancer  of  lung. 

three  Mediastinal  suppuration  ;  pleurisy  ;  peri- 
carditis. 

Perforation  of  trachea ;  broncho-pneu- 
monia. 


ON    DISEASES    OF    THE    (ESOPHAGUS. 


77 


No. 

Sex 

Afje 

Seat. 

Complications. 

37 
38 

F. 
F. 

31 

38 

Ditto 
Ditto 

Pneumonia  ;  ulceration  into  trachea. 
Broncho-pneumonia  ;  bronchi  full  of  fetid 

39 

40 
41 

M. 

M. 

M. 

65 

59 

70 

Ditto 

Ditto 
Vlid  oesophagus 

pus. 
Trachea  perforated  ;  secondary  cancer  of 
lung  and  kidney. 
Cancer  of  kidney. 
Inanition. 

42 
43 
44 

F. 
P. 
M. 

30 
58 
70 

Ditto 
Ditto 
Ditto 

Inanition  ;  trachea  opened. 
Pneumonia  ;  bronchus  opened. 
Trachea    perforated  ;     gastrotomy  ;    ex- 

hausted. 

45 

M. 

63 

Pour  inches  at  lower  end 

dancer  of  thyroid. 

46 

M. 

93 

Four     inches     from     middle 
downwards 

Inanition  ;  left  bronchus  opened. 

47 

M. 

61 

Two  inches  below  bifurcation 

Cancer  of  bones,  pleurae,  liver. 

of  trachea 

48 

M. 

47 

Two  inches  below  bifurcation 

Gangrene  of  right  lung;  perforation  of 

pleura. 

49 

F. 

51 

Three   inches   long   opposite 

Sloughing  lung. 

bifurcation 

50 

M. 

38 

^ower  two  inches 

Cancer  of  liver. 

51 

M. 

50 

jower  end 

Extension  to  the  right  lung  ;  sloughing 

pneumonia. 

52 

M. 

73 

Ditto 

Cancer  of  lung,  pericardium,  kidneys. 

53 
54 
55 

M. 
M. 
M. 

53 
50 
64 

)itto 
)itto 
STear  cardia 

Cancer  of  liver  ;  gangrene  of  the  lung. 
Cancer  of  glands,  lungs,  liver. 

56 

F. 

31 

Jpper  part 

57 

F. 

42 

)itto 

58 

M. 

63 

Vhole  tube  affected 

59 

M. 

45 

jower  seven  inches 

60 

M. 

59 

""rom  cricoid  downwards 

61 

F. 

64 

)itto 

62 

M. 

51 

Jehind  cricoid 

63 

M. 

54 

^ear  cardia 

64 

M. 

55 

Middle 

65 

M. 

56 

<"rom     sixth     tracheal    ring 

downwards 

66 

F. 

60 

Jifurcation  of  bronchi 

Trachea  perforated  ;  exhaustion. 

67 

M. 

64 

Jpper  end 

Hemorrhage. 

68 

M. 

66 

Cardia 

Still  alive  when  reported. 

69 

M. 

47 

Middle 

Recurrent  nerve  implicated. 

70 

F. 

54 

Ditto 

71 

F. 

42 

)itto 

Inanition. 

72 

M. 

63 

x)wer  third 

Bronchitis  and  inanition. 

73 

M. 

30 

Cardia 

Inanition. 

74 

F. 

33 

Jpper  end 

Exhaustion  ;  trachea  opened. 

For  other  cases  of  gastrotomy  in  cancer  of  the  oesophagus,  see  Durham,  in  '  Holmes's 
System  of  Surgery.' 

Of  85  cases  collected  from  the  'Guy's  Post-mortem  Records,'  the 
'Pathological  Society's  Transactions,'  and  other  sources,  59  cases 
occurred  in  males,  26  in  females.  This  proportion  of  rather  more 
than  2  to  1  of  males  over  females  closely  agrees  with  that  obtained 
from  a  smaller  number  of  cases  in  the  previous  edition  of  this  work. 
Crisp,1  in"  tabulating  21  other  cases,  gives  a  still  larger  preponderance 


'Lancet,'  vol  ii,  p.  628,  1873. 


78 


ON    DISEASES    OF    THE    (ESOPHAGUS. 


to  the  males  affected.  Richardson,1  however,  states,  that  both  sexes 
are  affected  equally,  an  assertion  apparently  founded  on  a  very  small 
number  of  cases.  The  average  age  of  57  males  gives  55^  years, 
again  closely  agreeing  with  a  former  result,  and  also  with  that  given 
by  Crisp. 

Of  25  women,  the  average  is  44J  years.  It  thus  appears  quite 
evident  that  women  become  affected  with  oesophageal  cancer  at  a 
much  earlier  date  than  men,  the  average  being  11  years  earlier. 
This  is  quite  borne  out  by  examining  individual  cases ;  thus,  of  the 
females,  2  cases  occurred  at  30  ;  3  at  31 ;  6  more  between  32  and  38; 
or  a  total  of  11  out  of  25  under  40  years  of  age. 


From  30  to  40 
40  50 
50  60 
60  70 


Of  the  males — • 

30 

38  to  40 
45  50 
50  60 
60  70 
70  75 


11 
4 


25 


1 
5 

14 

14 

19 

4 

57 


The  youngest  patient  I  find  recorded  as  having  had  cancer  of  the 
oesophagus  was  aged  22,  mentioned  by  Dr.  Richardson  in  his  paper 
before  the  Medical  Society  ;2  but  the  sex  of  this  patient  is  not  stated. 

Chronic  affections  of  the  lung  are  interesting  in  relation  to  cancer; 
the  tubercles  may  be  of  a  cancerous  character,  and  set  up  chronic 
pneumonia;  or  with  true  cancer  in  the  oesophagus  the  lung  may  be 
affected  with  ordinary  strumous  disease,  and  the  most  careful  exami- 
nation may  fail  to  detect  any  trace  of  carcinornatous  product  in  the 
lung,  the  two  diseases  existing  independently  at  the  same  time. 

Again,  the  vomica  may  exist  at  the  apex  of  the  lung,  evidently 
of  a  chronic  character,  or  with  dense  iron-gray  lung  tissue  around  it 
aud  calcareous  degeneration.  In  another  instance  under  my  care 
there  was  a  vomica  at  the  apex,  and  the  history  indicated  that  cough 
had  existed  long  prior  to  the  dysphagia.  There  were  evident  signs 
of  phthisis  in  the  flattened  apex,  loud  bronchial  and  amphoric  respi- 
ration and  bronchophony  ;  had  there  not  been  present  the  cancer  of 
the  oesophagus,  it  would  have  been  considered  as  an  ordinary  instance 
of  pneumonic  phthisis.  In  the  exhaustion  which  was  consequent  on 
the  obstruction  of  the  oesophagus,  the  cough  continued  troublesome, 
and  a  few  days  before  death  acute  disease  of  the  lung  was  set  up, 
arising,  perhaps,  at  the  time  the  cancerous  growth  began  to  disinte- 
grate, or  from  atmospheric  changes. 

Among  the  85  cases,  the  longest  period  which  elapsed  between 
the  commencement  of  dysphagia  and  death  was  about  two  years, 


1  'Lancet,'  p.  596. 


Ibid.,  loc.  cit. 


ON    DISEASES    OF    THE    (ESOPHAGUS.  79 

several  were  three  to  seven  months,  and  in  two  still  less,  the  interval 
being  only  five  and  seven  weeks. 

The  diagnosis  is  sometimes  obscure ;  this  has  been  mentioned  in 
reference  to  annular  stricture,  and  perforating  ulcer  into  the  trachea. 
Where  we  find  chronic  disease  of  the  lung  with  dysphagia,  the  diao-. 
nosis  is  much  increased  in  difficulty,  because,  in  ordinary  phthisis, 
the  dysphagia  is  sometimes  exceedingly  severe.  This  remark  ap- 
plies especially  to  the  bronchitic  phthisis  of  advanced  life. 

Dysphagia  with  chronic  emaciation  is  the  prominent  symptom 
of  cancerous  disease,  but  sometimes  the  dysphagia  is  very  slight, 
and  the  sudden  onset  of  acute  secondary  disease  masks  the  primary 
mischief;  and,  again,  very  extensive  sloughing  of  the  oesophagus 
may  render  the  rejection  of  food  from  the  stomach  almost  impossible. 
It  is  sometimes  very  difficult  also  to  distinguish  between  cancerous 
disease  of  the  oesophagus  and  pressure  upon  the  tube  by  aneurismal 
or  other  tumors  ;  in  the  latter  instances  the  dysphagia  is  less  persist- 
ent, and  often  varies  according  to  the  position  of  the  patient,  the 
oesophagus  falling  away  from  an  aneurismal  tumor  of  the  aorta  as 
the  patient  leans  forward;  paroxysms  of  dyspnoea  are  also  frequently 
present  in  cases  of  arterial  disease.  Flatulent  distension  of  the 
stomach  and  disease  of  the  cardiac  orifice  may  simulate  disease  of 
the  oesophagus  itself. 

The  prognosis  is  in  all  these  cases  very  unfavorable ;  but  in  some, 
after  the  avoidance  of  irritating  and  solid  food,  or  after  the  use  of 
nutrient  enemata  for  several  days,  the  dysphagia  becomes  diminished 
in  a  marked  degree,  the  patient  is  able  to  partake  of  solid  food,  and 
we  may  be  led  to  take  a  more  favorable  view  of  the  case  than  is 
warranted  by  the  nature  of  the  malady.  Two  cases  admitted  into 
Guy's  Hospital  with  symptoms  of  cancerous  disease  of  the  oesophagus, 
men  about  sixty  years  of  age,  with  nearly  complete  dysphagia,  were 
so  much  relieved  as  to  leave  the  hospital;  when,  however,  we  find 
the  disease  extending  into  the  respiratory  passages,  or  into  the  large 
vessels,  we  may  fear  a  speedy  and  fatal  termination. 

These  remarks  suggest  to  us  the  proper  mode  of  treatment.  The 
most  bland  and  unirritating  diet  should  be  given,  as  milk,  eggs, 
jellies,  soups,  &c.  Solid  articles  of  food  should  be  abstained  from, 
at  least  for  a  time,  for  the  attempt  to  swallow  solids  produces  dis- 
tressing spasm  of  the  oesophagus ;  and  if  the  dysphagia  be  very 
severe,  nutrient  injections  should  be  administered,  so  as  to  allow 
complete  rest  to  the  diseased  structures.  Stimulants  and  cod-liver 
oil  afford  partial  relief,  and  check  the  progress  of  disease. 

Solution  of  potash  and  iodide  of  potassium,  with  vegetable  infu- 
sions, afford  relief  in  the  earlier  stages  of  the  complaint ;  so  also, 
nitric  and  hydrochloric  acids,  with  morphia  or  opium.  In  advanced 
cases,  where  there  is  extensive  cancerous  ulceration  and  excessive 
irritability  from  exposure  of  the  branches  of  the  pneurnogastric, 
internal  remedies  are  of  no  avail,  and  nutrient  injections  are  the  only 
means  of  prolonging  life. 

Opium  in  one  form  or  other  is  the  best  remedy  for  the  .secondary 
pneumonic  or  bronchitic  complications ;  to  give  mercurials  and  anti- 


80  ON    DISEASES    OF    THE    (ESOPHAGUS. 

mon j,  &c.,  is  to  exhaust  still  more  rapidly  the  already  ebbing  life  of 
the  patient. 

It  is  a  question  of  great  importance  how  far  bougies  may  be  used 
with  advantage  in  the  treatment  of  cancerous  obstruction  of  the 
oesophagus  and  the  trachea  or  bronchi,  the  occasional  entire  destruc- 
tion of  the  canal,  and  the  injury  which  sometimes  results  to  the 
walls  of  the  aorta,  are  each  of  them  serious  objections  to  its  use; 
and  I  have  very  frequently  seen  instances  in  which  a  bougie  would 
certainly  have  passed  into  the  bronchus,  and  led  probably  to  speedy 
death.  In  the  earlier  stages  the  bougie  may  usefully  serve  to  indicate 
the  precise  character  and  seat  of  the  disease,  and  also  dilate  the  nar- 
rowed passage,  but  it  should  always  be  used  with  extreme  caution. 
The  cauterization  of  stricture  of  the  oesophagus  was  resorted  to  about 
the  close  of  the  last  century;  and  Sir  Everard  Home,  in  his  'Practi- 
cal Observations  on  the  Treatment  of  Strictures  of  the  Urethra  and 
Oesophagus,'  records  several  instances  in  which  the  use  of  caustic 
bougies  was  followed  by  relief  of  the  severe  dysphagia.  Simple 
bougies  have  been  more  frequently  used,  often  with  benefit,  though 
sometimes,  as  I  have  just  remarked,  to  the  injury  of  the  patient.  A 
case  is  mentioned  by  Mr.  Fletcher,  in  his  '  Medical  and  Surgical  Ob- 
servations,' in  which  perforation  was  produced  at  the  termination  of 
the  pharynx,  and  suppuration  among  the  muscles  of  the  neck  fol- 
lowed; on  the  other  hand,  when  carefully  employed,  food  may  be 
introduced  into  the  stomach  by  oesophageal  tubes  in  cases  in  which 
spasmodic  stricture  prevents  the  passage  even  of  the  blandest  fluids. 

As  an  instance  of  the  beneficial  use  of  the  bougie,  I  may  refer  to 
the  following  case : 

A  patient  recently  under  my  care  in  Guy's  Hospital,  suffering 
from  severe  dysphagia,  complained  of  pain  about  the  level  of  the 
sternum.  He  was  forty-three  years  of  age,  by  trade  a  letter-carrier, 
and  for  twelve  months  the  symptoms  of  obstruction  in  the  oesophagus 
had  troubled  him;  but  he  had  not  found  that  the  symptoms  had 
generally  much  increased  since  the  time  when  he  first  noticed  them. 
The  dysphagia  sometimes  became  greater,  but  it  was  always  Avith 
great  difficulty  that  any  portion  of  solid  food  could  be  swallowed. 
He  was  a  spare  man ;  no  enlargement  could  be  felt  in  the  neck ;  there 
was  no  apparent  obstruction  in  the  pharynx,  nor  was  there  any  evi- 
dence of  pulmonary,  cardiac,  or  arterial  disease.  Several  attempts 
were  made  to  pass  bougies  into  the  stomach,  but  without  success; 
they  rested  about  the  level  of  the  sternum  ;  even  an  elastic  catheter 
could  not  be  introduced  beyond  that  point.  After  a  fe\v  days  I  re- 
quested the  patient  to  abstain  altogether  from  food,  and  fed  him  for 
one  week  entirely  by  nutrient  enernata;  at  the  end  of  that  time  a 
large  bougie  could  be  easily  passed  into  the  stomach;  the  rest  to  the 
canal  had  allowed  the  irritation  and  spasmodic  constriction  to  sub- 
side, and,  although  organic  stricture  still  existed,  solids  could  be  more 
easily  swallowed.  The  bougie  met  with  an  obstruction,  as  before 
said,  about  the  level  of  the  sternum,  and  about  three  inches  below 
the  first  a  second  obstruction  occurred,  indicating  probably  the  upper 
and  lower  limit  of  the  diseased  surface;  and  when  the  bougie  reached 


ON    DISEASES    OF    THE    (ESOPHAGUS.  8t 

the  constriction  the  coughing  of  the  patient  enabled  the  instrument 
to  pass  onwards.  Cod-liver  oil  and  a  nourishing  fluid  diet  were 
given,  and  the  patient  left  the  hospital  relieved. 

Of  the  74:  cases  the  upper  part  of  the  tube  was  affected  in  33, 
though  in  several  it  was  not  confined  to  that  part  alone.  In  30 
the  middle,  or  the  part  about  the  root  of  the  lung,  was  chiefly 
affected,  and  the  cardiac  end  only  in  10.  It  is  to  be  borne  in  mind, 
however,  that  the  proportions  which  these  numbers  represent  are 
not,  perhaps,  quite  correct,  for  it  is  by  no  means  infrequent  to  find 
disease  extending  from  the  cricoid  region  to  the  root  of  the  lung,  or 
from  the  latter  to  the  cardia,  so  that  several  inches  of  the  tube  are 
affected,  and  this  renders  it  difficult  to  decide  upon  the  precise  origin 
of  the  disease.  Two  cases  are  recorded  in  which  the  whole  length 
of  the  oesophagus  was  affected. 

It  is  not  of  much  importance,  however,  to  decide  as  to  the  precise 
position  in  which  the  disease  commences.  It  is  sufficient  for  clinical 
purposes  to  remember  that  the  tube  is  liable  to  be  affected  in  three 
parts — at  its  commencement,  its  middle,  and  its  termination.  In  all 
these  it  can  be  shown  that  the  surface  is  subject  to  increased  friction, 
and  that  the  liability  of  attack  is  in  proportion  to  the  amount  of 
irritation.  At  the  upper  part  this  irritation  is  greatest,  for  the  tube 
suddenly  contracts  from  a  large  pouch  into  a  somewhat  narrow  tube, 
and  the  food  is  compressed  so  as  to  be  moulded  to  the  reduced  size 
of  the  canal.  Subsequently  it  will  pass  along  smoothly  unless  inter- 
rupted by  further  obstruction,  and  this  is  likely  to  happen  near  the 
root  of  the  lung,  at  the  bifurcation  of  the  trachea,  and  again  at  the 
cardiac  end.  Again,  at  the  commencement  the  cartilaginous  struc- 
tures in  front  of  the  oesophagus,  and  the  occasional  swelling  of  the 
bronchial  glands,  are  causes  of  pressure  which  do  not  exist  at  the 
lower  part. 

If  the  proportions  be  taken  in  the  different  sexes,  however,  they 
are  found  to  be  somewhat  altered,  the  ratio  of  affections  of  the  upper 
to  those  of  the  middle  parts  being  as  19  to  20  in  males,  14  to  8  in 
females. 

The  trachea  was  perforated  in  13  cases,  and  in  the  majority  of 
these  the  disease  attacked  the  part  at  the  root  of  the  lung.  It  was 
not  always  so,  and  it  is  to  be  remembered  that  cases  of  simple  ulcera- 
tion  occasionally  occur  which  lead  to  a  communication  between  the 
two  passages. 

CASE  X.  Cancerous  Disease  of  Lower  Third  oj  (Esophagus.  Division 
of  Canal.  Life  prolonged  by  Use  of  Bougie.  Death  from  Bronchitis — 
A.  B_,  set.  63,  a  farmer,  who  had  led  an  active  life,  began  to  suffer  from 
impairment  of  his  health  nine  months  before  his  death.  His  appetite  failed, 
and  he  soon  began  to  suffer  from  difficulty  in  swallowing.  The  food  only 
appeared  to  reach  the  throat,  and  was  quickly  rejected.  He  had  an  irritable 
cough,  and  at  the  upper  part  of  the  right  lung  the  respiration  and  voice  were 
bronchial,  and  the  resonance  'on  percussion  was  impaired.  He  rapidly  lost 
flesh.  He  expectorated  a  large  quantity  of  glairy  mucus,  and  it  was  evident 
that  the  saliva  filled  the  oesophagus  above  the  obstruction,  and  when.it  reached 
the  throat  or  epiglottis  induced  cough.  Mr.  Durham  passed  a  bougie  to  the 
6 


82  ON    DISEASES    OF    THE    (ESOPHAGUS. 

seat  of  stricture,  and  found  it  at  the  lower  third  of  the  oesophagus.  By  the 
use  of  fluid  diet  and  soothing  remedies  partial  relief  was  afforded,  but  the 
obstruction  soon  became  complete,  and  nothing  could  be  swallowed  for  about 
two  months  before  death.  Mr.  Durham  was,  however,  able  to  introduce  a 
small  ocsophageal  tube  and  to  feed  the  patient,  gradually  increasing  the  si/e 
of  the  tube  ;  fluid  food  with  vegetable,  and  when  necessary  wine,  were  thus 
introduced  into  the  stomach  night  and  morning.  The  patient  gained  strength, 
and  was  able  to  go  out  for  a  drive.  Unfortunately  in  one  of'these  excursions 
he  took  cold ;  the  glands  at  the  angle  of  the  jaw  and  the  parotid  on  the  right 
side  became  swollen,  the  skin  at  the  part  became  erythematous  and  brawny, 
suppuration  followed,  and  an  incision  was  made.  The  ocsophageal  tube  was 
still  introduced  night  and  morning,  but  with  more  difficulty  on  account  of 
the  inability  to  open  the  mouth  freely.  The  tube  had  for  some  days  had  an 
offensive  smell  when  withdrawn,  as  if  it  had  come  into  contact  with  sloughy 
tissue,  and  the  examination  of  the  mucus  showed  cells,  which  were  very  sus- 
picious as  to  their  cancerous  character.  Bronchitis  then  came  on,  and  mucous 
crepitation  was  heard  at  both  bases,  and  on  the  right  side  there  was  some 
consolidation  of  the  lung.  The  temperature  rose  to  101.2°,  respiration  to  40 
per  minute,  the  pulse  to  120.  There  was  partial  delirium,  and  in  a  few  days 
he  sank.  On  inspection,  broncho-pneumonia  was  found,  especially  in  the 
right  lung;  the  lower  third  of  the  esophagus  was  affected  with  a  sloughing 
cancerous  growth,  which  had  divided  all  the  coats  of  the  oesophagus,  and  had 
formed  a  sloughy  cavity  in  the  posterior  mediastinum  ;  a  small  portion  of  the 
oesophagus  was  left  which  had  served  to  guide  the  bougie  to  the  lower  opening 
of  the  oesophagus.  If  the  life  of  the  patient  had  been  prolonged  for  a  few 
days  the  pleura  would  probably  have  been  perforated.  There  was  scarcely 
any  infiltration  of  the  glands,  and  no  direct  extension  into  the  lung. 

Although  in  this  case  life  was  cut  short  by  an  attack  of  bronchitis 
and  erysipelatous  inflammation  of  the  glands  of  the  neck,  there  can 
be  no  doubt  that  the  exhausted  state  of  the  nervous  system  rendered 
the  patient  more  susceptible  to  these  attacks.  The  introduction  of 
the  bougie,  which  was  very  skilfully  effected  by  Mr.  Durham  with- 
out pain  to  the  patient,  greatly  relieved  the  distressing  sense  of  thirst 
and  of  exhaustion  from  which  many  suffer,  and  prolonged  life  for 
several  mopths. 

CASE  XI.  Cancer  of  the  (Esophagus.  Sloughing  Pneumonia  ;  the  Pneu- 
mogastric  Nerve  involved. — James  R — ,  aet.  45,  was  admitted  into  Guy's 
Hospital,  November  21,  1854,  under  Sir  Wm.  Gull's  care,  and  died  Novem- 
ber 30th.  He  was  a  married  man,  a  laborer,  and  intemperate  in  his  habits. 
For  nine  weeks  prior  to  his  admission  he  had  been  unable  to  swallow  food 
with  comfort,  and  he  had  suffered  from  severe  pain  at  the  lower  part  of  the 
sternum.  From  that  time  he  lost  much  flesh  ;  and  cough,  with  pain  in  his 
side,  came  on.  He  vomited  occasionally,  and  had  burning  pain  at  the  ster- 
num ;  and  there  was  a  sense  of  nausea  when  he  began  to  eat.  On  admission, 
he  had  a  cachectic,  pale,  and  wretched  appearance  ;  he  was  troubled  with 
cough,  and  the  expectorated  matters  were  exceedingly  offensive.  At  the  apex 
of  the  left  lung  the  respiration  was  coarse,  at  the  base  of  the  right  lung  there 
were  signs  of  consolidation  ;  the  patient  sank  in  a  few  days.  The  severe 
pulmonary  symptoms  in  this  case  completely  masked  the  original  disease  of 
the  oesophagus  ;  for  a  short  time  it  was  believed  that  the  case  was  one  of 
pneumonia  with  old  disease  of  the  lung,  and  that  the  burning  pain  at  the 
sternum,  and  vomiting,  were  the  consequence  of  his  former  intemperate 


ON    DISEASES    OF    THE    (ESOPHAGUS.  83 

habits.  At  the  commencement  of  the  oesophagus  extensive  ulceration  was 
found  on  inspection ;  the  ulcer  was  four  or  five  inches  in  length,  irregularly 
tubercular  on  its  surface,  and  several  tubercles  were  situated^in  the  mucous 
membrane,  both  above  and  below  the  ulceration.  The  disease  extended  as 
low  as  the  root  of  the  lung,  but  the  lungs  themselves  and  the  pleura  were  free 
from  cancerous  disease.  The  tissue  external  to  the  oesophagus  was  exten- 
sively infiltrated,  especially  on  the  right  side,  and  some  of  the  bronchial 
glands  were  affected ;  the  right  pneumogastric  nerve  extended  through  the 
diseased  structures.  The  lower  part  of  the  pneumogastric  appeared  wasted, 
but  it  could  not  be  traced  satisfactorily  throughout,  having  been  divided  in 
the  inspection.  The  right  lung,  at  its  lower  lobe,  was  of  a  greenish  color, 
and  it  had  a  faint  gangrenous  odor ;  it  was  infiltrated  with  dirty  serum,  and 
was  imperfectly  consolidated.  The  bronchi  were  intensely  congested.  The 
remaining  parts  of  the  lungs  and  the  larynx  were  healthy.  The  heart, 
stomach,  liver,  intestines,  &c.,  were  also  healthy,  and  no  cancerous  disease 
could  be  detected  in  any  other  part. 

As  to  the  character  of  the  growth,  it  had  the  general  and  micro- 
scopical appearance  of  epithelial  cancer.  There  was  no  direct  com- 
munication between  any  of  the  large  bronchi  and  the  ulceration  of 
the  oesophagus ;  and  it  appeared  probable  that  the  right  pneumo- 
gastrio,  becoming  involved  in  the  disease,  had  predisposed  to  the 
pneumonic  inflammation  on  the  same  side.  The  case  prove  fatal  at 
an  earlier  period  than  usual,  for  the  patient  died  ten  weeks  from  the 
recorded  commencement  of  difficulty  in  swallowing;  and  the  diag- 
nosis was  rendered  obscure  by  the  extreme  severity  of  the  pulmonary 
symptoms. 

CASE  XII.   Cancer  of  the  (Esophagus,  of  the  drvical  Glands,  and  of  the 

Thyroid  Body.      Gangrene  of  the  Lung George  E — ,  aet.  73,  was  admitted 

into  Guy's  Hospital,  November,  1853,  in  an  extremely  emaciated  state,  and 
died  February,  1854.  He  was  a  table-cover  maker,  and  in  his  early  life  had 
been  intemperate.  Eight  months  before  his  admission  he  received  a  severe 
fall,  from  which  he  never  recovered  ;  and  two  months  later  he  began  to  sufi\-r 
great  pain  in  eating  solids,  and  he  had  occasional  attacks  of  vomiting.  These 
attacks  became  more  and  more  frequent,  and  latterly  almost  incessant.  He 
could  not  take  solid  food,  and  complained  of  intense  pain  at  the  cardiac  ex- 
tremity of  the  stomach.  Mr.  Callaway  passed  an  cesophageal  bougie,  but 
without  meeting  any  obstruction  in  its  passage.  The  vomiting  diminished 
soon  after  admission.  The  bowels  became  constipated,  and  continued  to  suf- 
fer severe  pain.  He  became  gradually  weaker,  and  on  February  5th  he 
vomited  a  considerable  quantity  of  dark-colored  fluid;  he  died  on  the  13th. 
At  the  central  part  of  the  oesophagus,  opposite  the  root  of  the  lung,  there  was 
a  large,  irregular  ulcer,  two  inches  in  length,  which  involved  the  whole  of 
the  tube  ;  at  the  upper  part  was  a  raised  circular  margin,  and  a  partially  de- 
tached ulcer  of  similar  character,  about  half  an  inch  in  diameter.  At  the 
root  of  the  right  lung  there  was  a  mass  of  sloughing  tissue,  which  was  infil- 
trated with  sanious  fluid,  and  the  adjoining  lung  was  consolidated.  At  the 
base  of  the  left  lung  there  was  a  circumscribed  mass  of  pulmonary  apoplexy 
with  pneumonia,  and  a  vomica  containing  thin  purulent  fluid.  The  cervical 
glands  and  the  thyroid  body  were  infiltrated  with  carcinomatous  product, 
white,  and  of  a  medullary  character.  The  heart  had  undergone  both  fatty 
and  fibroid  degeneration.  In  the  peritoneum  were  old  adhesions,  and  a  gran- 


84  ON    DISEASES    OF    THE    (ESOPHAGUS. 

ular  condition  of  the  surface  of  the  liver.     The  kidneys  were  also  granular 
and  contracted. 

Although  the  oesophagus  was  extensively  ulcerated  in  this  case, 
a  bougie  could  easily  be  introduced,  showing  that  spasmodic  con- 
traction was  the  principal  cause  of  the  obstruction  and  of  the  rejec- 
tion of  the  food.  In  this  instance  also,  the  bougie  might  easily  have 
passed  through  the  diseased  walls  of  the  oesophagus  into  the  posterior 
mediastinum,  or  into  the  pleura ;  and,  from  a  diagnostic  point  of 
view,  it  might  have  led  to  the  supposition  that  the  disease  was 
in  the  stomach  rather  than  in  the  oesophagus,  on  account  of  the 
absence  of  obstruction  to  the  passage.  As  we  have  previously  stated, 
great  care  must  be  exercised  in  the  use  of  these  instruments. 

CASE  XIII.  Epithelial  Cancer  of  the  (Esophagus,  Pancreas,  Liver,  and 
Kidneys.  7 he  Pneumogastric  Serves  involved.  Granular  Kidneys.  Chronic 
Pletiro-pneumonia,  with  Cancer.  Fibrous  Tumor  in  Uterus.  Cancer  of 
Supra-renal  Capsules  and  Semilunar  Ganglion — Jane  B — ,  aet.  63,  was 
admitted  Aug.  23,  1855,  under  Dr.  Addison's  care.  She  had  suffered  for 
nine  months,  and  the  first  symptom  was  pain  after  swallowing ;  no  tumor 
could  then  be  felt,  but  cancerous  disease  was  suspected.  After  admission,  a 
firm  mass,  at  the  scrobiculus  cordis,  about  the  size  of  a  hen's  egg,  could  be 
felt;  it  was  well  defined,  sensitive  on  pressure,  and  tolerably  distinct  pulsa- 
tion could  be  perceived  ;  the  food  was  at  once  regurgitated.  She  complained 
much  of  flatulence,  and  at  night  regurgitated  water  into  the  mouth.  At 
first,  vomiting  several  hours  after  food  was  the  principal  symptom.  Soon 
after  admission  the  food  was  at  once  returned ;  sometimes,  however,  it  was 
retained  for  several  days.  She  took  creasote  three  times  a  day,  and  opium 
at  night,  with  considerable  relief  for  a  short  time.  On  December  8th  I  ex- 
amined some  of  the  water  ejected  from  the  mouth,  but  could  not  discover  any 
cancer  cells  nor  sarcina.  She  varied  much,  sometimes  the  stomach  being 
excessively  irritable  and  rejecting  everything,  at  other  times  she  was  able  to 
take  food.  On  December  19th  the  tumor  had  not  increased  in  size.  She 
became  more  and  more  prostrate,  and  during  the  last  month  of  her  life  suf- 
fered severely.  She  died  March  26th.  On  inspection  the  body  was  much 
emaciated.  There  was  extreme  atrophy  of  the  brain,  notwithstanding  the 
absence  of  cerebral  symptoms.  Chest — At  the  commencement  of  the  oeso- 
phagus  the  mucous  membrane  began  to  present  an  irregular  granular  appear- 
ance, with  one  or  two  whitish  tubercles  about  the  size  of  pins'  heads  ;  passing 
downwards,  these  tubercles  became  more  numerous,  till  nearly  opposite  the 
root  of  the  lung  an  ulcerated  surface  was  i'ound,  with  a  raised  margin  and 
partially  sloughing ;  still  lower  in  the  canal  than  this  ulcer  the  walls  of  the 
oesophagus  were  completely  destroyed  for  about  three  inches,  and  the  side  of 
the  right  lung  was  in  a  sloughy  condition ;  posteriorly  the  pericardium 
bounded  this  sloughy  mass,  and  there  was  an  opening,  about  the  size  of  a 
sixpence,  extending  through  that  membrane,  opposite  the  left  auricle,  which 
was  slightly  affected  with  granular  cancerous  growth  at  that  part.  Nearer  to 
the  stomach  the  walls  of  the  oesophagus  were  again  continuous,  but  infiltrated 
with  cancerous  product,  and  nearly  in  a  sloughy  condition.  At  the  floor  of 
the  cancerous  ulcer  were  several  branches  of  the  pneumogastric  exposed ; 
the  right  nerve  could  be  traced  down  to  the  ulcer,  and  several  branches  were 
completely  truncated ;  another  branch  of  the  right  nerve  passed  obliquely 
across  the  ulcer  to  the  opposite  side,  to  join  the  left  nerve.  On  the  left  side 
a  branch  was  also  observed  to  be  truncated,  and  another  ran  for  about  two 


ON    DISEASES    OF    THE    (ESOPHAGUS.  85 

inches  exposed  in  the  sloughy  tissue.  The  branches  to  the  lungs  were  entire, 
and  were  situated  above  the  cancerous  growth.  The  ulcer  in  the  oesophagus 
presented  the  elements  of  epithelial  cancer.  Cancerous  tubercles  of  epithe- 
lial nature  were  found  in  both  lungs,  with  some  iron-gray  pneumonia  at  the 
left  apex.  Abdomen — In  the  stomach,  near  the  cesophageal  opening,  was  a 
raised  tubercular  growth  about  half  an  inch  in  diameter  ;  it  was  ulcerated  at  its 
apex  ;  its  section  showed  that  it  principally  involved  the  mucous  membrane, 
but  was  extending  into  the  muscular  coat  beneath.  Some  large  nucleated 
cells  were  observed  in  the  raised  edges  of  the  growth,  and  degenerated  gastric 
follicles ;  some  of  the  follicles  were  much  enlarged,  containing  highly  re- 
fracting particles,  others  contained  nuclei.  The  rest  of  the  mucous  mem- 
brane and  the  pylorus  were  healthy.  The  head  of  the  pancreas  formed  the 
hard  mass  which  had  been  felt  at  the  scrobiculus  cordis  ;  it  was  hard  and 
white,  and  microscopically  epitheliomatous.  The  adjoining  lymphatic  glands 
were  intiltrated  and  adherent ;  the  lesser  curvature  of  the  stomach  was  also 
adherent ;  the  rest  of  the  pancreas  was  normal.  On  the  adjoining  surface  of 
the  liver  was  an  irregular  tubercle,  evidently  produced  by  contact,  and  in  the 
substance  were  several  other  small  tubercles,  but  consisting  of  the  same  epi- 
thelial elements.  On  the  right  side  the  cancerous  infiltration  extended  to 
the  right  semi-lunar  ganglion,  which  appeared  to  be  infiltrated  with  cancer- 
ous product,  cancerous  cells  being  observed  among  the  ganglionic  cells. 
There  were  cancerous  tubercles  in  both  supra-renal  capsules,  but  only  involv- 
ing a  small  portion  of  the  organ.  The  kidneys  were  granular,  very  small, 
and  only  four  ounces  in  weight.  The  cavity  of  the  uterus  was  occupied  by  two 
soft  polypi,  and  a  large  dense  tumor,  about  three  inches  in  diameter,  was 
found  in  its  walls  ;  the  tumor  was  dense  and  fibrous  and  calcareous,  but  did 
not  present  any  trace  of  cancerous  elements.  (See  Preparation  179933.) 

In  this  case  the  diagnosis  was  obscure,  on  account  of  the  food 
being  sometimes  retained  for  several  hours;  and  this  symptom  ap- 
peared to  indicate  disease  of  the  stomach  rather  than  of  the  oesopha- 
gus. A  tumor  could  also  be  felt  at  the  scrobiculus  cordis;  the 
disease  of  the  oesophagus  was,  however,  too  extensive  to  produce 
obstruction,  the  walls  of  the  lower  part  of  the  canal  being  entirely 
destroyed  ;  the  injury  of  the  pneumogastric  was  very  extensive,  and 
the  exposure  of  its  branches  was  probably  the  cause  of  the  severe 
pain  from  which  the  patient  suffered. 

CASE  XIV.  Epithelial  Cancerous  Tumor  in  the  Pharynx,  closing  the 
entrance  into  the  (Esophagus.  Effusion  of  False  Membrane  in  the  Larynx 

and   Trachea.     Acute  Bronchitis Charlotte  W — ,  jet.   32,  was  admitted 

under  Mr.  Cock's  care,  February,  1856,  and  died  March  6th.  She  had  been 
out  of  health  for  a  year,  but  for  three  months  she  had  experienced  very  great 
difficulty  in  swallowing,  and  for  several  days  it  had  become  almost  impossible 
to  swallow  anything  except  a  small  quantity  of  fluid ;  and  the  attempt  now 
led  to  regurgitation  through  the  nares.  The  eifort  of  swallowing  did  not 
produce  urgent  dyspnoea.  Respiration  on  admission  was  easy  and  normal, 
but  there  was  slight  hoarseness.  On  examining  the  chest,  the  respiration 
was  found  to  be  less  free  at  the  right  apex.  At  the  left  side  of  the  neck, 
below  the  angle  of  the  jaw,  was  a  prominent  round  tumor  about  one  inch  in 
diameter;  it  could  be  partially  separated  from  the  structures  beneath.  Mr. 
Cock  attempted  to  pass  a  small  bougie,  but  this  was  found  to  be  quite  impos- 
sible. The  tumor  in  the  throat  could  neither  be  seen  nor  felt.  A  short  time 
before  death  very  urgent  dyspnoea  came  on,  and  she  died  from  apnoea.  At 


86  OX    DISEASES    OF    THE    (ESOPHAGUS. 

the  lower  part  of  the  pharynx,  attached  to  the  cricoid  and  arytenoid  carti- 
lages, or  rather  the  mucous  membrane  opposed  to  llu-ni,  were  four  round 
tumors  closely  placed  together,  or  rather  one  lohulated  growth,  extending  as 
high  as  tlie  upper  margin  of  the  epiglottis,  and  quite  occluding  the  opening 
into  the  oesophagus.  After  removal,  a  probe  could  only  be  inserted  by  slowly 
passing  it  round  the  growth.  The  soft  palate  was  considerably  thickened. 
The  inner  surface  of  the  epiglottis,  of  the  larynx,  and  of  the  trachea,  was 
covered  by  a  layer  of  easily  separable  false  membrane  ;  the  bronchi,  especially 
the  larger  ones,  were  full  of  tenacious  mucus.  The  tumor  in  the  neck  was 
soft,  and  of  a  pale  yellow  color.  All  other  parts  were  noimal.  On  examin- 
ing the  growth  from  the  pharynx,  its  base  was  found  to  consist  of  large 
cancer  cells,  containing  a  large  granular  nucleus,  and  the  cells  were  closely 
arranged  together.  The  growth  in  the  neck  had  a  similar  structure.  The 
surface  was  not  ulcerated,  but  presented  epithelium,  which  was  normal  in 
some  parts.  The  appearance  of  the  papilla-  has  been  previously  referred  to; 
some  were  in  a  normal  condition  ;  in  others,  the  central  capillary  was  ob- 
structed, and  some  wrere  still  more  degenerated,  closely  resembling  brood 
cells.  (Prep.  178576.) 

The  obstruction  at  the  commencement  of  the  oesophagus  in  this 
case  was  mechanical,  and  the  cause  of  death  secondary  laryngitis. 
The  diagnosis  of  tumor  was  easy,  but  it  was  found  to  be  quite 
impossible  to  pass  any  instrument  beyond  the  growth.  Many  in- 
stances of  non-cancerous  polypi  are  recorded,  and  some  may  be  re- 
moved by  operation ;  in  this  case  the  groAvth  was  too  low  to  be 
reached,  and  its  character  was  less  suited  for  operative  interference. 

CASE  XV.  Carcinoma  of  the  (Esophagus,  communicating  u'ith  the 
Trachea.  Cancer  of  the  Lung  and  of  the  Kidney — Catherine  S — ,  set.  38, 
admitted  under  Dr.  Barlow's  care,  April  9th,  185G,  and  died  April  17th.  Sin- 
had  been  a  servant  in  a  family  for  twenty  years,  and  began  to  suffer  from 
her  present  illness  about  six  months  before  her  death.  On  admission  she 
was  in  a  state  of  great  emaciation,  and  the  dysphagia  was  extreme.  The 
attempt  to  swallow  food  was  at  once  followed  by  the  regurgitation  of  it 
through  the  nose  and  mouth.  The  circulation  was  exceedingly  feeble,  and 
Dr.  Barlow  feared  lest  gangrene  might  come  on.  She  appeared  to  die  from 
exhaustion.  The  body  was  much  emaciated.  In  the  neck,  on  the  left  side, 
was  an  enlarged  cervical  gland,  about  one  inch  in  diameter,  firmly  adherent 
to  the  oesophagus  and  to  the  trachea ;  a  smaller  gland  was  situated  on  the 
right  side;  the  former  tumor  could  be  felt  before  the  division  of  the  skin. 
The  lungs  did  not  collapse  freely.  On  dividing  the  trachea  an  opening  into 
the  oesophagus,  somewhat  oval  in  form,  slightly  pointed  above  and  below, 
and  about  one  inch  and  a  half  long,  was  found  immediately  above  the  division 
into  the  bronchi  ;  the  edges  of  this  opening  were  thickened  and  slightly  irre- 
gular. The  corresponding  part  of  the  oesophagus  in  its  whole  circumference 
presented  a  nodular  surface  for  three  inches  in  length.  The  edges  were 
raised  and  irregular,  and  the  surface  ulcerating,  and  there  was  slight  vascular 
turgescence  of  the  mucous  membrane.  Several  cervical  glands  which  were 
adherent  to  the  oesophagus  were  infiltrated  with  cancerous  deposit;  they  were 
of  a  firm  consistency,  and  were  white  in  color,  but  in  the  centre  yellow. 
Other  glands  at  the  root  of  the  lung  were  not  all  infiltrated.  The  bronchi 
were  intensely  congested,  and  contained  much  dirty  grumous  fluid.  The 
lower  lobes  of  the  lungs  were  much  congested,  and  the  right  contained  beneath 
the  pleura  a  small  mass,  about  half  an  inch  long  and  a  quarter  of  an  inch 


ON    DISEASES    OF    THE    (ESOPHAGUS.  87 

broad,  composed  of  yellowish-white  cancerous  substance.  The  left  renal  vein 
was  filled  with  adherent  clot,  and  its  walls  were  considerably  thickened.  In 
this  kidney  were  several  cysts,  and  a  minute  tubercle  composed  of  elements 
resembling  the  other  cancerous  structures.  On  examination  of  the  oesopha- 
geal  ulcer  a  small  quantity  of  juice  from  the  section  presented  numerous 
nuclei,  mnd  in  the  section  some  epithelial  plates,  cells  with  large  nuclei,  and 
caudate  cells.  It  also  presented  some  elongated  nuclei  and  fibres,  some  ot 
which  had  a  curved  arrangement,  inclosing  nuclei  and  brood  cells.  The 
raised  edges  of  the  ulcer  were  composed  of  masses  of  these  nuclei  and  cells, 
with  some  intervening  elongated  nuclei  and  fibres,  and  on  the  addition  of 
acetic  acid  some  elastic  coiled  fibres  were  observed.  The  growth  in  the  lun" 
presented  similar  aggregations  of  nuclei.  The  cervical°glands  were  of  a 
much  firmer  texture,  and  much  fibrous  tissue  was  observed  in  them,  forming 
irregular  interspaces,  in  which  nuclei  were  found.  The  central  portion's 
were  yellow,  and  contained  highly  refracting  granules  (degenerating  cancer). 
The  great  number  of  large  nuclei  resembled  those  found  in  medullary  cancer, 
and  this  case  appeared  to  be  almost  intermediate  between  medullary  and 
epithelial  disease. 

CASE  XVI.  Cancer  of  the  (Esophagus.  Extension  into  the  Lung. 
Gangrene — James  S — ,  aet.  57,  was  admitted  under  my  care  into  Guy's 
Hospital  May  12th,  1858,  and  died  June  4th.  For  many  years  he  had  been 
a  coachman,  and  temperate  in  his  habits.  In  1832  he  had  been  ill  for  six 
Aveeks  with  pain  across  the  chest,  and  for  many  years  he  had  had  cough. 
Eight  weeks  before  admission,  on  attempting  to  eat,  he  felt  that  he  was 
unable  to  swallow,  and  from  that  time  he  could  take  no  solid-  food  ;  the  food 
seemed  to  pass  as  far  as  the  scrobiculus  cordis,  and  was  then  rejected.  He 
was  a  pale  and  emaciated  man;  the  thoracic  viscera  were  normal,  the  abdo- 
men was  supple,  and  no  tumor  could  be  detected,  but  pulsation  was  very 
distinct  at  the  scrobiculus  cordis.  The  superficial  epigastric  veins  were 
slightly  enlarged  ;  he  complained  of  weakness  and  vertigo.  On  the  21st  he 
had  gaseous  eructations,  which  increased  the  dysphagia.  On  the  25th  food 
was  instantly  rejected,  and  the  vomiting  produced  a  "  cutting"  pain  in  the 
epigastrium ;  at  other  times  the  pain  wras  of  a  dull  character.  When  un- 
mixed with  food  the  rejected  matters  consisted  of  tenacious  mucus.  He  died 
June  4th.  On  inspection  the  termination  of  the  oesophagus  was  diseased. 
For  the  space  of  an  inch  there  was  cancerous  deposit  infiltrated  into  the 
mucous  and  submucous  tissues,  as  also  into  the  muscular  layer.  The  canal 
was  much  contracted,  so  that  a  small  probe  only  could  be  passed.  On  the 
right  side  the  growth  was  adherent  to  the  lung ;  the  cancerous  tissue  was  at 
that  part  ulcerated,  and  communicated  with  the  lung  tissue,  which  was  in  a 
sloughing  state.  The  upper  lobe  of  the  right  lung  contained  pneumonic  de- 
posit and  several  small  cavities.  The  other  viscera,  and  the  lymphatic  glands 
were  in  a  healthy  state.  The  examination  of  the  growth  showed  much  firm 
fibrous  tissue,  and  some  cells  of  epithelial  cancer. 

CASE  XVII.  Cancer  of  the  (Esophagus.  Pneumonia.  The  Pneiimo- 
gastric  Nerve  involved John  D — ,  a3t.  71,  was  admitted  into  Guy's  Hos- 
pital, on  January  26th,  1859.  For  two  years  he  had  been  under  observation, 
and  he  had  also  previously  been  in  the  hospital.  The  difficulty  in  swallow- 
ing, and  the  emaciation,  had  increased  to  an  extreme  degree,  but  he  was  able 
to  get  some  food  down  until  two  or  three  days  before  his  death,  when  the 
symptoms  of  pneumonia  came  on.  On  inspection,  eleven  hours  after  death, 
the  body  was  found  to  be  much' wasted.  The  oesophagus  was  contracted  one 
inch  above  the  bifurcation  of  the  trachea,  the  walls  were  thickened,  and  there 


88  ON    DISEASES    OF    THE    (ESOPHAGUS. 

was  adventitious  deposit  effused  in  a  circumscribed  manner  in  the  submuoous 
cellular  tissue.  Some  of  the  neighboring  glands  were  slightly  infiltrated. 
There  was  pleuro-pneumonia  of  the  left  lung,  the  whole  being  gray  and  solid, 
with  a  dark-colored  gray  fluid  exuding  from  it ;  but  there  was  no  sloughing. 
The  left  pneumogastric .  was  involved  in  the  diseased  structure  of  the 
oesophagus.  The  heart  and  liver  were  healthy ;  so  also  the  gall  bladder  and 
the  ducts.  The  kidneys  were  degenerated,  only  five  ounces  in  weight,  and 
they  contained  a  few  cysts.  The  diseased  cesophageal  substance  consisted  of 
fibrous  and  elastic  tissue,  squamous  epithelium,  large  nuclei  and  cells  in 
considerable  quantity,  aggregated  in  clusters  ;  and  some  of  these  clusters  of 
cells  were  limited  by  membrane,  as  if  forming  part  of  a  glandular  structure. 

CASE  XVIII.  Cancer  of  the  (Esophagus.  The  left  Pneumogastric  in- 
volved. Pneumonia — William  E — ,  set.  50,  was  admitted  July  30th,  1856, 
under  Mr.  Callaway's  care,  and  died  September  18th.  He  had  suffered  from 
dysphagia  for  six  months,  and  could  not  swallow  solids.  He  had  cough,  and 
expectorated  tenacious  mucus.  His  cough  and  expectoration  became  worse, 
and  the  lung  tissue  involved.  During  the  last  week  of  his  life  he  swallowed 
with  more  ease.  The  ulceration  in  the  oesophagus  extended  from  the  cricoid 
cartilage  to  the  bifurcation  of  the  trachea;  the  edge  was  well  defined,  raised, 
and  yellowish  ;  the  central  part  was  ulcerated,  and  the  whole  circumference 
of  the  oesophagus  involved  ;  in  front,  the  cartilages  of  the  trachea  were  exposed, 
and  immediately  above  the  bifurcation  was  an  opening  about  the  size  of  a 
sixpenny  piece,  with  irregular  serrated  margins..  The  ulceration  extended 
downwards  and  outwards,  and  was  closely  connected  with  the  external  surface 
of  the  left  bronchus ;  it  had  involved  the  pneumogastric  nerve  on  that  side, 
one  of  the  larger  branches  of  which  was  completely  destroyed.  Posteriori}', 
the  vertebras  formed  the  boundary  of  the  ulceration.  The  greater  part  of  the 
lower  lobe  of  the  left  lung  was  in  a  state  of  gray  hepatization,  and  towards 
the  apex  there  was  some  iron-gray  hepatization,  with  whitish  tubercles.  These 
tubercles  appeared  to  be  of  a  cancerous  character.  In  the  right  lung  was 
another  small  mass  of  condensed  lung.  There  was  slight  infiltration  of  the 
adjoining  bronchial  glands.  On  microscopical  examination  both  the  ulcer 
and  bronchial  glands  were  found  to  be  epitheliomatous. 

The  more  easy  deglutition  during  the  last  week  of  life  is  possibly 
explained  by  the  extension  of  the  ulcer  having  destroyed  the  whole 
of  the  circumference  of  the  oesophagus  and  also  the  nerves,  and  there- 
by preventing  any  spasmodic  obstruction.  The  pneumonia  of  the 
left  lung  was  no  doubt  accelerated  by  the  injury  to  the  nerve  on  that 
side ;  but  it  must  be  borne  in  mind  that  the  cancerous  growth  ex- 
tended to  the  left  bronchus. 

CASE  XIX.  Cancer  of  the  (Esophagus.  Communication  with  the  left 
Bronchus.  The  Pneumogastric  involved.  Old  Vomica  in  the  Lung.  Exten- 
sion of  Disease  through  the  Diaphragm. — George  W — ,  aet.  53,  was  admitted, 
under  my  care,  September  3d,  1856;  he  was  emaciated  and  gray;  he  had 
been  a  blacksmith  at  Chatham,  and  on  the  day  of  admission  came  from  the 
North  Foreland.  Until  six  weeks  before,  he  had  enjoyed  good  health  ;  at 
that  time  he  experienced  pain  in  swallowing  food,  especially  solids,  which 
were  almost  at  once  rejected.  He  had  pain  across  the  sternum.  On  the  6th, 
he  became  more  prostrate  ;  the  hiccough  was  distressing ;  the  motions  were 
black  ;  and  he  brought  up  brownish-colored  blood ;  he  gradually  sank,  and 

died  on  the  8th,  at  2  A.  M.      (Esophagus Two  or  three  inches  from  the 

commencement  of  this  canal  were  several  small  ulcerated  surfaces,  of  a  pale 


ON    DISEASES    OF    THE    (ESOPHAGUS.  89 

yellowish  color,  with  central  depression  ;  an  inch  further  the  whole  of  the 
walls  of  the  oesophagus  were  destroyed,  and  the  margin  defined  ;  beyond  this 
part  was  an  irregular  flocculent  gray  tissue,  floating  out  when  placed  in  water; 
it  was  formed  upon  a  dense  fibro-cartilaginous  base,  firmly  adherent  to  the 
trachea,  aorta,  and  other  tissues ;  an  inch  from  the  left  bronchus  was  a  cir- 
cular opening,  about  three-quarters  of  an  inch  in  diameter,  forming  a  com- 
munication between  the  oesophagus  and  the  bronchus  ;  the  latter  tube  con- 
tained a  flocculent  gray  mass,  which  almost  obstructed  it.  Some  of  the 
bronchial  glands  were  partially  infiltrated.  The  pneumogastric  nerve  extended 
into  the  dense  tissue  at  the  base  of  the  ulceration,  and  some  of  its  branches 
were  exposed  at  the  floor  of  the  ulcer.  The  destruction  of  the  oesophagus 
extended  to  the  diaphragm,  and  the  ulceration  passed  through  it,  so  as  to  form 
an  irregular  sloughing  cavity  below  that  muscle,  bounded  by  the  stomach,  by 
the  cellular  tissue,  by  the  large  vessels,  and  partly  by  the  left  lobe  of  the 
liver.  The  cardiac  opening  into  the  stomach  remained  in  its  normal  condi- 
tion, and  near  it  was  a  second  opening  from  the  abscess  just  mentioned.  The 
ulceration  also  extended  into  the  liver.  The  branches  of  the  sympathetic  were 
partially  destroyed,  but  could  not  be  satisfactorily  dissected ;  some  of  them  were 
very  hard,  but  on  microscopical  examination,  nerve  fibre,  apparently  undegene- 
rated,  could  be  detected.  The  coronary  artery  of  the  stomach  was  obstructed  by 
clot ;  some  of  the  glands  at  the  lesser  curvature  of  the  stomach  were  infiltrated. 
The  ulceration  almost  extended  into  the  thoracic  aorta;  that  vessel  was  exceed- 
ingly diseased,  from  atheromatous  and  calcareous  deposit,  and  in  two  parts  had  a 
greenish  appearance  ;  there  seemed  to  be  a  minute  communication  beneath  a 
bony  plate  with  the  ulcer  in  the  oesophagus,  but  no  probe  could  be  passed.  On 
examining  the  upper  margin  of  the  cesophageal  ulcer,  large  cancer  cells  were 
detected  and  some  nuclei ;  the  surface  of  the  flocculent  growth  consisted  of 
pointed  processes  filled  with  granules,  sometimes  several  proceeding  from  one 
trunk.  The  stomach  was  exceedingly  contracted  and  of  hour-glass  form ;  the 
mucous  membrane  was  healthy.  The  left  lobe  of  the  liver,  which  was  some- 
what enlarged,  almost  obscured  the  stomach  ;  the  liver  itself  appeared  healthy, 
its  weight  was  3  Ibs.  At  the  apex  of  the  left  lung  was  an  old  vomica,  surrounded 
by  iron-gray  lung  and  calcareous  deposit ;  its  lining  was  smooth,  and  it  was 
capable  of  containing  about  Jss  of  fluid.  The  pleura,  on  the  left  side,  was  uni- 
versally adherent ;  on  the  right  side  it  was  partially  so  at  the  apex,  The 
right  lung  also  contained  a  small  vomica,  but  there  were  no  tubercles  in  it ;  a 
small,  white,  dense  tubercle  was  situated  beneath  the  right  pleura.  The  re- 
maining part  of  the  lungs  was  oedematous.  The  pericardium  contained  an 
excess  of  fluid  ;  the  heart  and  its  valves  were  healthy  ;  the  weight  of  the 
heart  was  9^  ounces.  The  kidneys  were  atrophied,  and  contained  several  cysts. 

The  pain  at  the  sternum,  the  difficulty  in  swallowing  solids,  the 
emaciation,  the  cachexia,  the  age,  all  indicated  organic  disease  of 
the  oesophagus.  The  general  bronchial  rales  pointed  to  some  com- 
munication having  been  set  up;  and  this  was  believed  to  be  proba- 
ble. There  was  no  pain  at  the  scrobiculus  cordis,  nor  was  there  any 
apparent  indication  of  the  abscess  which  existed.  The  prostrate 
condition  of  the  patient  had  prevented  the  development  of  more 
manifest  peritonitis. 

The  disease  had,  probably,  existed  for  a  longer  period  than  six 
weeks,  if  we  judge  by  the  destruction  of  nearly  the  whole  oesophagus, 
and  the  firm  character  of  the  tissue  which  bounded  it.  It  was  evi- 
dently cancerous,  although  no  other  parts  except  those  in  immediate 


90  ON    DISEASES    OF    THE    OESOPHAGUS. 

contact  were  affected.  But  the  villous  and  flocculent  character  of 
the  growth,  with  evident  cancer  cells  at  the  margin  of  the  liberation, 
appeared  to  indicate  that  it  somewhat  differed  from  ordinary  epi- 
thelial cancer.  The  small  vomica  at  the  left  apex  was  not  diagnosed; 
it  had  remained  in  a  passive  condition,  but  its  association  with  can- 
cerous disease  was  an  exceedingly  interesting  phenomenon.  It  is 
doubtful  whether  any  blood  oozed  from  the  aorta,  or  whether  that 
effused  was  from  the  coronary  artery  of  the  stomach. 

The  stimulants  and  food  probably  passed  into  the  cavities  which 
Lad  been  formed  in  the  mediastinum,  and  tended  rather  to  irritate 
than  to  produce  effectual  benefit. .  Nothing  more,  however,  could 
have  been  done,  except,  perhaps,  by  the  use  of  nutrient  injections ; 
but  as  the  patient  could  swallow  fluids  and  retain  them,  these  means 
appeared  scarcely  to  be  called  for. 

CASE  XX.  Cancer  of  (Esophagus.  Pneu  mo  gastric  Nerves  truncated. 
Sloughing  extending  through  the  Lung  and  through  the  Diaphragm — John 
H — ,  set.  45,  was  admitted  into  Guy's  Hospital  Februsiry  17th,  and  died 
March  2,  1858.  He  was  a  tall,  emaciated  man,  who  had  been  ill  for  several 
years.  He  had  no  dysphagia,  but  the  food  was  generally  rejected  at  once  ; 
sometimes,  however,  it  was  retained.  He  had  no  pain  between  the  shoulders, 
nor  on  pressure  at  the  region  of  the  stomach.  He  gradually  sank,  luajtcr. 
tion. — In  the  right  lung  the  lobules  were  consolidated  very  generally,  and 
were  infiltrated  with  offensive  serum.  At  the  root  of  the  lung,  below  the 
vessels,  was  a  circumscribed  slough  communicating  with  the  diseased  oesopha- 
gus. The  left  lung  was  affected  in  a  similar  manner,  but  in  a  less  degree. 

(Esophagiis At  the  root  of  the  lung  the  tube  was  irregularly  truncated,  and 

a  large  sloughing  cavity  was  formed,  bounded  by  the  lungs;  the  cavity  was 
encroached  upon  anteriorly  by  the  posterior  surface  of  the  pericardium.  At 
the  lower  part  the  diaphragm  had  sloughed  ;  and  the  sloughing  cavity  was 
limited  below  by  the  pancereas,  by  the  anterior  surface  of  the  stomach,  and  a 
small  portion  of  the  liver.  The  pneumogastrics  were  both  truncated.  In 
the  stomach,  at  the  cardiac  orifice,  there  was  an  irregular  infiltration  of  the 
mucous  membrane  by  cancerous  product,  and  two  openings  extended  into  the 
sloughing  cavity  before  mentioned ;  these  openings  were  bevelled  on  their 
inner  aspects.  The  rest  of  the  stomach  was  healthy.  There  was  no  glan- 
dular enlargement,  nor  disease  of  the  spleen,  liver,  intestines,  etc.  The  peri- 
cardium was  adherent,  the  heart  small,  the  valves  healthy. 

The  physician  who  had  the  care  of  this  case  regarded  it  as  one  of 
pyloric  disease,  on  account  of  the  remarkable  absence  of  pain  and 
difficulty  in  swallowing,  after  the  patient  came  under  observation  in 
the  hospital.  This  immunity  probably  arose  from  the  manner  in 
which  the  oesophagus  and  its  nerves  were  truncated. 

CASE  XXI.  Medullary  Cancer  of  the  (Esophagus.  Chronic  Pneumonia. 
Vomica.  Acute  Pneumonia — William  G — ,  ret.  GO,  had  been  an  attorney, 
but  he  had  become  reduced  in  circumstances;  for  twelve  months  he  had  had 
cough  and  shortness  of  breath,  sometimes  palpation  of  the  heart,  but  no 
haemoptysis;  for  twelve  months  also  he  had  pain  across  the  chest,  but  no  ex- 
pectoration ;  his  health  continued  tolerable  till  two  months  before  I  saw  him, 
when  he  first  experienced  difficulty  in  swallowing;  this  gradually  increased 
in  severity,  so  that  he  was  only  able  to  swallow  liquids,  and  that  with  con- 
siderable pain.  The  pain  was  situated  about  the  level  of  the  third  rib,  at  the 


ON    DISEASES    OF    THE    (ESOPHAGUS.  91 

sternum,  the  sensation  being  as  if  a  foreign  body  was  retained  at  that  part  ; 
the  ability  to  swallow  was  occasionally  relieved,  but  never  completely  so. 
There  was  evidence  of  old  disease  at  the  apex  of  the  right  lung,  and  acute 
bronchitis  with  it  ;  with  these  were  associated  tolerably  clear  evidence  of 
organic  disease  of  the  oesophagus,  probably  cancerous.  In  this  condition  he 
was  admitted  into  Guy's ;  he  was  requested  not  to  attempt  to  swallow,  for 
this  effort  produced  spasmodic  contraction  of  the  oesophagus  ;  several  nutrient 
enemata  were  given.  The  following  day  he  swallowed  with  greater  facility, 
and  could  take  beef  tea,  eggs,  and  milk,  with  a  little  brandy ;  his  cough, 
however,  was  more  troublesome  ;  the  sputum  was  purulent,  nummulated,  and, 
on  microscopical  examination,  presented  no  evidence  of  cancer  cells,  but 
some  curved  elastic  fibre,  resembling  lung  structure,  and  large  inflammatory 
granule  cells.  After  admission  no  food  or  milk  was  vomited.  He  continued 
in  the  same  state  for  some  time,  but  gradually  sank  in  about  two  months, 
deatli  being  preceded  by  occasional  delirium.  On  inspection,  the  lung  was 
found  to  be  very  firmly  adherent  to  the  right  apex,  and  a  thick  dense  layer 
of  fibrous  tissue  was  with  great  difficulty  separated  ;  the  whole  of  the  right 
pleura  was  destroyed ;  on  making  a  section  of  the  right  lung,  a  small  vomica 
was  found  at  the  apex  surrounded  with  iron-gray  lung,  the  surface  was 
smooth  ;  the  lower  lobe  was  in  a  state  of  hepatization.  The  lower  lobe  of  the 
left  lung  was  also  pneumonic  ;  the  pleura  over  it  being  covered  with  a  thin 
layer  of  lymph.  Some  of  the  bronchial  glands'  were  slightly  infiltrated  with 
cancer,  but  there  was  no  evidence  of  cancer  in  the  lungs. 

In  the  oesophagus  was  an  ovoid  mass,  about  six  inches  in  length  and  one 
in  thickness,  attached  at  the  root  of  the  lung,  and  reaching  nearly  to  the 
cricoid  cartilage;  the  canal  was  dilated;  the  mass  was  of  a  pale  yellowish 
color,  and  was  softened  in  the  centre;  it  was  attached  only  to  one  side  of  the 
tube,  and  no  smaller  tubercles  were  observed  on  the  mucous  membrane ;  no 
communication  with  the  trachea  or  bronchi  existed;  the  tumor  consisted  of 
nuclei  and  nucleated  cells  resembling  medullary  cancer;  none  of  the  brood 
cells  usually  found  in  epithelial  cancer  were  observed.  The  pneumogastric 
nerves  were  free,  and  the  disease  appeared  to  have  commenced  in  the  mucous 
membrane.  The  heart  was  healthy ;  so  also  the  abdominal  viscera ;  the  in- 
testinal canal  was  much  contracted,  but  contained  solid  feces.  The  liver 
was  slightly  congested,  and  the  gall  bladder  was  much  distended. 

The  existence  of  a  disease  so  closely  resembling  pneumonic  phthisis, 
as  that  found  in  this  case  was  very  interesting,  when  we  consider  it 
in  connection  with  the  cancerous  disease  of  the  oesophagus,  and  with 
the  age  of  the  patient.  It  was  my  opinion,  during  life,  that  the 
disease  in  the  oesophagus  had  extended  into  the  bronchi,  but  this 
was  not  found  on  inspection.  The  only  other  disease  which  appeared 
to  be  probable  as  a  cause  of  the  dysphagia  was  aneurism ;  but  the 
persistence  of  the  dysphagia  in  every  position,  and  the  absence  of 
other  signs  of  aneurism,  led  me  to  believe  that  the  obstruction  was 
of  a  cancerous  character.  If  the  patient  had  been  much  younger  it 
might  easily  have  been  supposed  that  the  case  was  one  of  ordinary 
phthisis,  with  severe  ulceration  about  the  larynx  and  epiglottis:  we 
had  evidence  of  chronic  disease  of  the  lung,  with  acute  disease;  and 
in  phthisis  the  dysphagia  is  sometimes  exceedingly  severe  and  dis- 
tressing; but  the  patient  did  not  lose  his  voice,  the  food  was  never 
regurgitated  through  the  nose,  nor  did  it  produce  spasmodic  cough; 
the  obstruction  was  evidently  below  the  epiglottis. 


92  ON    DISEASES    OF    THE    (ESOPHAGUS. 

No  attempt  was  made  to  explore  the  oesophagus  with  any  bougie 
or  tube;  the  danger  and  discomfort  which  would  have  arisen  from 
it,  did  not  warrant  such  an  attempt  being  made.  The  use  of  nutrient 
enemata,  even  for  a  single  day,  removed  the  very  urgent  dysphugia 
which  existed  on  his  admission.  The  patient  had  previously  tried 
to  swallow;  till  he  found  himself  exhausted. 

CASE  XXII.      Cancer  of  the  (Esophagus.     Artificial  Opening  made  into 

the  Stomach Walter  H — ,  ret.  47,  was  admitted  into  Guy's  Hospital  October 

8th,  1857,  under  my  care.  He  had  resided  at  Tunbridge  Wells  as  a  stable- 
man, was  of  ordinary  stature,  light  complexion,  and  moderately  nourished. 
He  stated  that  for  sixteen  years  he  had  had  winter  cough,  but  that  he  had 
never  had  dropsy.  On  admission  there  was  considerable  dyspnoea;  the  lips 
purplish;  the  pulse  compressible,  but  regular;  the  chest  was  resonant  on 
percussion,  and  the  respiratory  murmur  indistinct;  distant  prolonged  expira- 
tory murmur  was  everywhere  audible,  with  some  sibilant  rale;  the  voice  was 
also  indistinct,  and  tactile  vibration  diminished.  The  heart-sounds  were  regu- 
lar and  normal;  the  expectoration  frothy  and  moderately  abundant.  The 
abdomen  was  moderately  full  and  rounded,  and  there  was  a  small  hard  gland 
felt  about  the  anterior  margin  and  upper  part  of  the  sterno-mnstoid  muscle. 
After  he  had  been  in  the  hospital  for  a  short  time,  he  began  to  complain  of 
severe  pain  in  the  throat  during  coughing;  but,  on  carefully  examining  the 
part,  nothing  could  be  perceived.  In  a  few  weeks  pain  was  also  produced 
in  swallowing,  especially  when  solids  were  taken,  and  the  cough  continued 
unrelieved.  On  December  14th,  he  continued  to  suffer  severely,  and  became 
more  anaemic;  the  countenance  was  expressive  of  great  distress,  and  the  mind 
irritable;  deglutition  had  become  very  difficult,  so  that  he  could  only  take 
fluid  forms  of  food,  and  some  stimulant.  The  cough  also  was  very  trouble- 
some, producing  very  severe  pain  in  the  throat ;  it  was  violent,  and  small 
drops  of  blood  were  spirted  out  in  the  act  of  coughing  ;  the  expectoration  was 
thin  and  watery.  The  chest  continued  resonant;  respiration  was  very  fee- 
ble ;  on  the  left  side  it  was  indistinct,  and  the  expiratory  murmur  was  pro- 
longed ;  the  larynx  was  free  in  its  movements.  Nothing  could  be  seen  in  the 
throat,  except  slight  oedema  and  redness  towards  the  right  side.  The  gland 
at  the  angle  of  the  jaw  remained  of  the  same  size ;  the  pulse  was  compressi- 
ble ;  the  tongue  clean  ;  the  bowels  confined.  Various  means  were  tried,  as 
conium  and  carbonate  of  soda,  with  hydrocyanic  acid,  steel,  etc.  The  bowels 
were  acted  upon  by  colocynth  and  henbane,  by  magnesia  mixture,  or  by  injec- 
tions. Counter-irritation  was  applied  to  the  throat — hot-water  fomentation, 
or  cataplasm,  blisters,  &c.  The  inhalation  of  steam  afforded  some  relief,  but 
still  more  the  smoking  of  stramonium  leaves.  Tincture  of  aconite,  applied 
externally,  was  also  of  some  benefit.  Mr.  Cooper  Forster  examined  the  throat 
for  me,  but  could  not  detect  any  cause  of  obstruction.  The  patient  continued 
during  January  and  February  without  any  improvement,  the  emaciation 
increased,  and  both  respiration  and  deglutition  became  more  difficult,  espe- 
cially the  latter.  Morphia  was  occasionally  given,  and  stramonium  inhaled, 
affording  partial  relief.  On  again  examining  the  throat,  Mr.  Forster  felt 
below  the  epiglottis,  towards  the  right  side,  a  rounded  tumor,  which  was  evi- 
dently obstructing  the  commencement  of  the  oesophagus,  and  he  believed  that 
its  surface  was  ulcerated.  The  respiration,  although  noisy  and  accompanied 
with  a  loud  inspiratory  sound,  was  not  hurried,  and  sufficient  a'r  appeared  to 
enter  the  larynx.  The  propriety  of  performing  tracheotomy  was  discussed, 
but  it  was  decided  that  no  benefit  was  likely  to  accrue  from  it.  The  exami- 
nation of  the  growth  in  the  throat  was  followed  by  temporary  relief,  and  the 


ON    DISEASES    OF    THE    (ESOPHAGUS.  93 

patient  was  able,  for  three  or  four  clays,  to  swallow  solid  food.  The  stramo- 
nium and  other  remedies  were  continued,  and  nourishment  was  given  in  any 
form  that  could  be  taken.  On  March  1st  the  emaciation  was  very  much 
increased.  During  inspiration  a  loud  noise  was  produced  in  the  throat ;  and 
this  sound  had  for  some  weeks  been  increasing  in  intensity,  so  that  he  had 
been  unable  to  sleep  for  several  nights,  on  account  of  the  "  roaring,"  as  he 
termed  it.  His  voice  had  become  more  feeble,  but  the  cough  had  almost 
ceased  ;  he  could  only  swallow  fluids,  and  those  very  slowly  ;  his  nourishment 
latterly  had  consisted  of  milk  and  rum,  with  eggs.  Deglutition  was  much 
relieved  for  two  or  three  days  by  two  small  blisters  applied  on  either  side  of 
the  larynx ;  but  it  again  became  so  difficult  that  nutrient  injections  were 
resorted  to.  These  injections,  by  allowing  the  throat  to  rest,  had  enabled 
him  to  swallow  with  more  comfort.  The  pulse  was  very  compressible  and 

small ;  the  bowels  occasionally  constipated.      March  2d The   respiration 

became  more  difficult,  and  by  the  advice  of  Mr.  Stocker  tracheotomy  was 
performed.  The  incision  was  made  as  low  as  possible,  but  the  trachea 
appeared  flattened  from  behind,  and  the  patient  could  not  bear  the  insertion 
of  the  tracheal  tube ;  when  it  was  attempted  he  appeared  to  be  quite  inca- 
pable of  breathing.  The  operation  did  not  afford  relief,  and  a  deep-toned 
rhonchus  could  be  heard  in  the  lungs.  There  was  no  congestion  of  the  face ; 
the  pulse  was  very  compressible ;  the  cough  slight ;  he  was  able  to  get  down 
his  rum  and  milk,  and  some  blanc-mange,  &c.  On  the  9th  he  was  breathing 
more  comfortably ;  the  opening  in  the  throat  was  patent,  and  thin  pus  cov- 
ered the  red  margins  of  the  wound  ;  there  was  also  less  noise  on  inspiration. 
24th. — The  emaciation  and  prostration  of  strength  increased  ;  his  bones 
appeared  barely  covered  with  thin  skin,  and  the  face  expressive  of  starvation. 
He  said  "  he  was  famished."  He  endeavored  to  relieve  his  distressing  thirst 
by  moistening  the  mouth,  but  for  four  days  he  had  not  been  able  to  swallow 
a  drop  of  fluid.  The  attempt  to  swallow  at  my  request  was  preceded  by  much 
hesitation  and  preparation,  and  was  followed  by  a  paroxysm  of  severe  cough- 
ing. The  expectoration  had  changed  in  character,  and  had  become  muco- 
purulent.  On  examining  the  chest  sibilant  rales  were  everywhere  faintly 
audible.  There  was  no  dulness  on  percussion,  but  preternatural  resonance. 
The  voice  was  very  feeble  and  scarcely  audible ;  the  pulse  slow  and  very 
compressible ;  the  tongue  clean  ;  the  larynx  was  movable  ;  the  gland  at  the 
angle  of  the  jaw  had  not  enlarged ;  the  opening  in  the  skin  made  during  tra- 
cheotomy remained  open,  and  the  skin  was  undermined,  there  being  evidently 
no  power  to  repair  the  wound.  The  abdomen  was  exceedingly  contracted,  the 
pulsation  of  the  aorta  being  visible,  and  the  arteries  most  distinctly  traceable. 
There  was  no  evidence  of  enlargement  of  the  liver,  nor  of  disease  of  the 
abdominal  viscera.  He  complained  of  pain  towards  the  right  side,  and  tied  a 
handkerchief  firmly  around  him  to  relieve  the  sense  of  hunger.  The  skin 
was  dry.  He  passed  about  a  pint  and  a  half  of  urine  during  the  day.  The 
sleep  was  tolerable  ;  the  mind  clear  and  active.  Nutrient  injections  of  beef 
tea,  eggs,  and  rum,  thickened,  if  possible,  with  flour,  had  been  given,  at  tirst 
four  times  and  then  six  times  a  day.  Milk  also  was  ordered,  and  n^v  of 
tincture  of  opium  were  added  to  each  injection.  On  the  25th  he  appeared  to 
be  sinking,  and  the  rectum  ejected  the  enemata  almost  at  once.  His  hands 
were  cold,  but  he  complained  of  a  sense  of  heat. 

It  now  became  a  question  whether  life  was  to  be  allowed  gradually 
to  die  out,  or  an  attempt  to  be  made  by  any  other  means  for  the 
introduction  of  food  ;  the  patient  appeared  to  have  chronic  bronchitis, 
with  epithelial  cancer  at  the  commencement  of  the  oesophagus, 


94  OX    DISEASES    OP    THE    OESOPHAGUS. 

possibly  extending  into  tho  trachea,  and  death  threatened  from 
inanition.  Three  modes  of  relief  suggested  themselves — 1st,  the 
forcible  introduction  of  an  oesophageal  tube ;  2d,  opening  the 
oesophagus  in  the  neck ;  and  3d,  opening  the  stomach.  In  reference 
to  the  first,  there  was  evidence  of  a  growth  at  the  commencement  of 
the  oesophagus ;  and  the  trachea  appeared  partially  compressed,  as 
shown  in  the  operation  of  tracheotomy.  The  disease  in  the  throat 
was  probably  of  the  form  of  epithelial  cancer,  and  the  passage  of  a 
bougie  must  have  been  constantly  repeated.  The  great  irritation 
and  coughing  produced  by  attempting  to  swallow,  showed  that  the 
epiglottis  was  extensively  ulcerated ;  or,  that  there  was  a  communi- 
cation between  the  oesophagus  and  trachea,  which  would  render  the 
passage  of  a  bougie  very  dangerous.  In  some  cases  of  cancer  of  the 
oesophagus,  a  bougie  has  been  passed  into  the  pleura,  and  led  to  a 
speedy  death ;  and  probably  the  passage  of  a  bougie  could  not  have 
been  effected ;  this  decided  against  the  first  proceeding.  As  to  the 
second,  namely,  opening  the  oesophagus,  since  a  very  frequent  seat 
of  cancer  in  that  tube  is  opposite  to  the  root  of  the  lung,  about  the 
third  dorsal  vertebra,  and  consequently  beneath  the  position  at  which 
the  canal  could  be  opened,  the  operation  would  have  been  very 
formidable,  dangerous,  and  even  useless.  The  third  proposition, 
that  of  opening  the  stomach,  appeared  to  be  the  only  operation  which 
could  possibly  relieve  the  patient. 

"Wounds  of  the  stomach,  as  that  of  Alexis  St.  Martin,  the  cases 
recorded  by  Mr.  South  and  by  Dr.  Murchison,  &c.,  showed  that  life 
could  be  continued  after  a  fistulous  communication  had  been  thus 
made.  The  operations  on  the  lower  animals  proved  that  it  could  be 
performed  with  some  probability  of  success ;  such  an  operation 
would  give  a  chance  of  prolonged  life,  where  death  was  otherwise 
certain ;  and  where  the  peritoneum  was  healthy,  there  was  less 
danger  than  in  abnormal  conditions  of  that  membrane.  If  life  were 
prolonged  only  for  a  short  time,  and  food  introduced,  there  would 
be  relief  to  the  distressing  thirst  and  the  fearful  sense  of  starvation: 
and,  lastly,  it  was  evident  that  the  patient  was  dying  from  inanition 
rather  than  from  the  disease,  nutrient  enemata  being  refused.  On 
the  other  hand,  however,  I  felt  that  the  disease  was  probably  of  a 
cancerous  character,  and  would  sooner  or  later  terminate  life ;  that 
the  operation  was  a  hazardous  and  uncertain  one;  and  that  life 
might  possibly  be  continued  for  a  few  days  by  a  small  portion  of 
the  injection  being  retained.  After  carefully  weighing  these  facts,  I 
asked  the  assistance  of  my  colleague,  Mr.  Cooper  Forster,  and  if  he 
considered  the  operation  of  opening  the  stomach  through  the  anterior 
abdominal  parietes,  for  the  purpose  of  introducing  food,  a  feasible 
and  warrantable  one,  I  decided  that  it  should  be  attempted.  The 
operation  was  accordingly  performed,  and  the  stomach  was  opened 
by  an  incision  commencing  at  the  extremity  of  the  eighth  rib,  and 
the  edges  were  stitched  to  the  wound.  March  26th. — The  operation 
took  place  about  half-past  2  P.  M.,  and  was  borne  without  a  move- 
ment on  the  part  of  the  patient.  The  pulse,  which  before  the  opera- 
tion was  62,  and  exceedingly  compressible,  rose  to  116.  Six  drachms 


OX    DISEASES    OF    THE    (ESOPHAGUS.  95 

of  milk  with  part  of  an  egg  were  introduced  through  an  elastic  tube 
into  the  stomach.  At  twenty  minutes  past  3,  about  two  ounces  more 
milk  and  egg  were  introduced ;  the  patient  then  complained  of  feel- 
ing a  sense  of  heat,  but  appeared  comfortable.  He  was  now  removed 
to  bed.  At  4  P.  M.  the  pulse  was  120  and  still  very  feeble ;  it  was 
decided  to  introduce  every  half  hour,  if  the  patient  were  awake,  two 
ounces  of  milk  and  egg,  and  every  second  time  two  drachms  of  rum 
with  it.  At  9  P.  M.  he  was  comfortable ;  there  had  been  slight  pain 
in  the  left  side ;  the  pulse  was  fuller,  124 ;  the  skin  less  parched ; 
and  he  had  slept  occasionally  for  a  short  time.  Messrs.  Greenwood, 
Gayleard,  Owen,  and  Tuck,  kindly  volunteered  to  remain  with  him 
iii  rotation.  During  the  night  he  had  four  hours'  sleep,  he  passed 
urine,  and  there  were  three  slight  watery  evacuations  from  the 
bowels.  27th. — About  10  A.M.  he  coughed  violently,  and  the  con- 
tents of  the  stomach  were  forcibly  ejected  through  the  wound.  His 
pulse  continued  120.  At  1  P.M.  he  was  cheerful,  his  eyes  more 
bright,  his  voice  stronger,  the  skin  less  parched,  his  tongue  moist, 
thirst  and  the  sense  of  starvation  relieved ;  he  had  pain  in  the  left 
side ;  the  pulse  120,  and  very  compressible ;  his  hands  were  cold, 
feet  and  legs  warm  ;  the  coldness  of  the  hands  had  been  very  marked 
for  several  days.  The  operation  had  evidently  mitigated  his  suffer- 
ing. At  1.30  P.  M.  half  an  ounce  of  rum,  with  sugar,  and  an  ounce 
and  a  half  of  water,  and  fifteen  minims  of  lemon -juice  were  given. 
The  stomach  received  it  well,  contracting  upon  the  tube.  He  said 
that  it  produced  a  comfortable  sense  of  warmth  throughout  the  abdo- 
men. At  3.30  the  pulse  was  firmer  and  fuller  than  at  1  o'clock,  and 
the  hands  warmer.  Since  the  operation,  during  the  twenty-four 
hours,  he  had  six  eggs,  beaten  up  in  twelve  ounces  of  milk,  given  in 
small  divided  doses,  with  four  ounces  of  rum.  Milk  and  egg,  or 
beef  tea  thickened  _  with  flour,  were  ordered  every  half  hour,  and 
occasionally  half  an  ounce  of  rum,  as  just  mentioned.  At  8.30  P.  M. 
faintness  came  on,  the  face  became  cold  and  perspiring ;  pulse  136, 
and  scarcely  to  be  felt.  The  stomach  appeared  to  have  lost  its  power 
of  contracting  on  the  food  introduced. 

Stimulants  were  ordered  to  be  given  repeatedly  and  freely,  with 
nourishment  as  before ;  and  two  or  three  times,  as  a  stimulant,  KIXX 
of  tincture  of  sesquichloride  of  iron.  During  the  night  he  was  evi- 
dently sinking,  the  pulse  sometimes  became  scarcely  perceptible,  but 
rallied  after  stimulants  were  introduced.  On  the  28th  he  slept  for  a 
short  time  about  10  A.  M.,  and  expressed  himself  as  comfortable,  but 
gradually  became  unconscious,  and  died  at  10.45,  rather  more  than 
forty-four  hours  after  the  operation. 

The  inspection  was  made  twenty-eight  hours  after  death.  The 
body  was  extremely  emaciated.  The  head  was  not  examined.  At 
the  lower  part  of  the  neck,  immediately  above  the  sternum,  was  the 
wound  made  in  tracheotomy,  gaping  and  undermined,  and  on  the 
trachea  a  few  drops  of  pus.  At  the  left  hypochondrium  was  the 
opening  made  by  the  operation  of  gastrotomy  also  enlarged  by  the 
plug  which  had  been  introduced  a  few  hours  before  death.  The 
mouth  and  soft  palate  were  healthy,  also  the  epiglottis.  At  the 


96  ON    DISEASES    OF    THE    (ESOPHAGUS. 

posterior  surface  of  the  cricoid  cartilage  there  was  a  growth  con- 
nected with  the  mucous  membrane,  about  a  quarter  of  an  inch  in 
elevation,  and  extending  from  side  to  side,  soft  and  slightly  injected ; 
passing  downwards,  there  was  irregular  ulceration,  and  towards  the 
trachea  destruction  of  all  the  coats  of  the  oesophagus;  on  either  side 
and  below,  the  ulcer  was  bounded  by  a  sharp  undermined  edge. 
The  cellular  tissue  of  the  trachea  and  its  muscular  fibres  were  de- 
stroyed for  about  half  an  inch  ;  the  mucous  membrane  was  bare,  and 
perforated  by  a  small  opening  about  one-sixteenth  of  an  inch  in 
diameter,  so  that  fluid  could  pass  from  the  oesophagus  into  the 
trachea ;  below  the  ulcerated  surface  in  the  oesophagus  the  canal  was 
much  contracted  by  infiltration  into  the  surface  of  the  mucous  mem- 
brane ;  the  passage  was  so  much  diminished  at  this  part  that  a  probe 
could  only  be  passed  after  death,  and  it  was  probably  quite  im- 
pervious to  fluids  during  life.  The  constriction  was  situated  at  the 
level  of  the  first  bone  of  the  sternum.  The  rest  of  the  oesophagus 
was  healthy.  One  or  two  glands  in  the  neck  were  infiltrated  and 
diseased,  but  none  of  the  mediastinal  or  other  glands.  The  rima 
glottidis  was  free  ;  the  vocal  cords  and  aryteno-epiglottidean  folds 
were  quite  healthy  ;  so  also  was  the  trachea.  The  bronchi  contained 
thick  tenacious  mucus.  The  pleura  on  the  left  side  was  healthy  ;  on 
the  right,  there  were  general,  but  not  firm  adhesions.  The  lungs 
were  both  much  distended  with  air ;  they  were  pale,  emphysematous, 
and  covered  the  heart.  At  the  right  apex  the  lung-tissue  was 
puckered ;  there  were  numerous  lobules  of  iron-gray  consolidation, 
with  intervening  crepitant  lung,  but  no  disorganization.  The  lower 
lobe  of  the  right  lung  afforded  a  beautiful  speciman  of  emphysema, 
but  there  were  numerous  gray  tubercles  studded  in  small  clusters ; 
they  were  non-cancerous.  The  lower  lobe  of  the  left  lung  was  much 
congested,  and  one  or  two  lobules  were  softened. and  breaking  down 
from  acute  changes,  which  took  place,  probably,  a  very  short  time 
before  death.  There  was  no  enlargement  of  the  bronchial  glands. 
In  front  of  the  surface  of  the  heart  was  a  small  collection  of  pus, 
only  a  few  drops,  apparently  from  the  inflammation  of  a  small  gland. 
The  pericardium  and  heart  were  healthy ;  the  heart  was  contracted 
and  firm.  On  opening  the  abdomen,  the  intestines  were  found  con- 
tracted; the  peritoneum  was  healthy ;  no  inflammation,  as  shoiun  by 
effusion  of  lymph,  serum,  or  diminution  of  the  normal  smoothness,  could 
be  detected.  The  stomach  was  partially  distended ;  it  was  situated 
lower  than  usual,  and  its  anterior  surface  was  looped  up  to  the 
opening  in  the  anterior  abdominal  parietes  made  by  Mr.  Forster  at 
the  linea  semilunaris.  The  mucous  membrane  of  the  stomach  was 
pale,  slightly  injected  at  the  opening.  On  gently  drawing  aside  the 
stomach  at  the  opening,  the  opposed  serous  surfaces  were  found 
slightly  adhering.  The  small  intestine  was  healthy  throughout,  but 
atrophied ;  the  food  introduced  had  only  passed  four  feet  down  the 
intestine ;  below  that  point  the  intestine  was  exceedingly  small. 
The  lower  part  of  the  ileum  was  healthy.  In  the  colon  there  was 
several  patches  of  congested  mucous  membrane.  The  gall-bladder 
was  distended,  the  liver  healthy,  so  also  the  kidneys ;  the  spleen  was 


OX    DISEASES    OF    THE    (ESOPHAGUS.  97 

very  small.  There  was  no  evidence  of  any  cancerous  disease  affecting 
any  part  except  the  oesophagus  and  one  or  two  adjoining  glands. 

It  is  probable  that  chronic  disease  of  the  riglit  apex  had  existed 
for  a  long  time,  so  also  the  emphysema  of  the  lungs.  Other  miliary 
tubercles  were  perhaps  of  recent  deposition.  The  lobular  consolida- 
tion and  congestion  of  some  parts  of  the  left  lower  lobe  of  the  lung 
were  evidently  only  of  very  brief  duration.  As  to  the  cause  of  the 
cancerous  disease  we  have  no  evidence;  it  was  probably  of  about 
six  months'  duration;  its  existence  with  chronic  disease  of  the  lung 
is  a  fact  of  some  pathological  interest.  The  microscopical  examina- 
tion of  the  growth  in  the  neck  presented  the  form  of  cells  commonly 
observed  in  epithelial  cancer. 

In  reference  to  the  diagnosis  in  this  case,  it  was  evident  at  the 
time  of  admission  that  the  patient  had  chronic  disease;  he  had  had 
cough  for  fifteen  years;  there  was,  however,  no  evidence  of  serious 
obstruction  to  the  heart  or  to  the  portal  circulation ;  the  dysphagia 
was  then  a  new  symptom.  The  examination  of  the  chest  did  not 
give  any  indication  of  phthisis,  the  respiration  was  exceedingly 
feeble  at  the  apices,  but  there  was  no  dulness  on  percussion,  and  the 
voice  was  diminished  rather  than  increased  in  resonance;  at  the 
bases  the  expiratory  murmur  was  prolonged;  it  appeared  probable 
that  there  was  no  marked  consolidation  of  the  lung,  but  rather  that 
the  feebleness  of  the  respiratory  act  was  due  to  emphysema.  The 
question  arose,  whether  there  was  any  pressure  on  the  right  bronchus, 
but  of  this  there  was  no  proof;  the  respiration  at  the  right  base  was 
as  strong  as  at  the  left,  and  there  was  no  increase  of  resonance  at 
the  right  apex,  though  the  respiration  was  less  distinct.  As  to  the 
cause  of  the  dysphagia,  it  was  naturally  suggested  whether  it  was  a 
case  of  phthisis,  in  which  the  principal  disease  manifested  itself  in 
the  throat,  by  ulceration  of  the  epiglottis.  I  have  several  times 
observed  in  severe  ulceration  of  the  epiglottis  very  severe  dys- 
phagia; and  the  condition  may  be  mistaken  for  obstructed  oesopha- 
gus. Few,  however,  would  have  had  that  idea  in  this  case,  for  there 
was  wanting  at  the  early  stage  the  raucedo  of  phthisis;  and  the  diffi- 
culty in  swallowing  was  evidently  at  a  later  stage  of  the  process 
than  that  produced  by  ulceration  of  the  epiglottis:  there  the  attempt, 
to  swallow  is  scarcely  commenced  before  the  food  is  ejected,  often 
through  the  nares;  here,  it  passed  beyond,  there  was  no  such  ejec- 
tion of  food,  but  rather  severe  pain,  and  that  extending  to  the  ears. 
The  blood  also  which  was  spirted  out  during  coughing  was  not  as 
we  observe  it  in  ulcerated  larynx,  but  was  evidently  from  the  pha- 
rynx. Subsequently  a  tumor  could  be  felt  at  the  commencement  of 
the  oesophagus.  The  emaciation  was  not  that  of  simple  phthisis: 
there  we  generally  have  a  rounded  abdomen,  and  often  more  or  less 
diarrhoea;  here  there  was  uniform  constipation  and  collapsed  abdo- 
men. There  was  no  evidence  of  syphilis  to  account  for  the  affection 
of  the  throat,  nor  of  aneurism.  It  was  presumed  that  the  affection 
of  the  pharynx  and  oesophagus  was  of  the  form  of  epithelial  cancer; 
the  enlarged  gland  in  the  neck  confirmed  this  idea,  and  there  was 
nothing  to  indicate  any  such  disease  of  other  viscera.  As  to  the 
7 


98  ON    DISEASES    OF    THE    (ESOPHAGUS. 

prognosis,  that  was  from  the  first  unfavorable,  but  it  was  not  for 
several  weeks  anticipated  that  such  serious  disease  of  the  throat 
would  present  itself;'  all  idea  was  then  given  up  of  ultimate  recovery. 
In  the  treatment,  the  object  was  to  relieve  the  irritation  of  the  bronchi 
and  the  engorgement  of  the  portal  system;  and  to  strengthen  the 
patient,  meat  diet  was  given.  The  excreting  organs  and  glands  were 
acted  on  by  squill  and  blue  pill,  by  purgatives,  &c.  The  spasmodic 
contraction  of  the  bronchi  was  relieved  by  conium,  alkalies,  hydro- 
cyanic acid,  and  stramonium.  The  pain  produced  by  swallowing 
and  coughing  was  most  distressing,  and  sometimes  kept  the  patient 
awake  for  several  nights.  Inhalation  of  steam  afforded  relief,  so 
also  the  smoking  of  the  leaves  of  stramonium.  The  application,  of 
nitrate  of  silver  aggravated  the  distress;  but  small  blisters  on  either 
side  of  the  throat  were  productive  of  the  greatest  benefit;  tincture 
of  aconite,  also,  applied  externally  was  more  palliative  than  chloro- 
form; morphia  administered  internally  produced  transient  compo- 
sure; all  these  means,  however,  could  not  check  the  progress  of  the 
disease.  When  it  became  necessary  to  resort  to  nutrient  injections, 
life  was  fast  ebbing  away.  It  may  be  a  question  as  to  what  is  most 
effective  in  such  cases;  beef  tea  thickened  with  flour,  an  egg,  and  a 
small  quantity  of  rum  were  used.  Sir  W.  Gull  suggested  the  pro- 
priety of  using  pepsine  mixed  with  the  fluid,  and  since  the  rectum 
is  incapable  of  rendering  the  aliment  in  a  condition  ready  for  absorp- 
tion, it  may  be  well  deserving  of  trial.  The  longest  period  in  which 
I  have  known  a  patient  nourished  by  injections  alone,  was  in  a  case 
mentioned  by  Dr.  Barlow,  in  which  for  seventy  days  food  was  ad- 
ministered only  in  this  manner.  In  my  patient  the  rectum  much 
more  quickly  refused  injections.  All  other  means  of  affording  relief 
being  taken  away,  as  stated  in  describing  the  case,  I  was  brought 
to  the  consideration  of  gastrotomy.  I  had  previously  ventured  to 
suggest  this  operation  in  impending  starvation,  in  cases  of  perforation 
or  communication  between  the  oesophagus  and  trachea,  where  deglu- 
tition is  sometimes  impossible.  Death  in  these  cases  sometimes 
takes  place  simply  from  inanition.  In  this  instance,  it  was  well 
known  that  there  was  incurable  disease,  and  that  any  operation 
which  might  be  performed  would  only  be  palliative.  It  was  sub- 
mitted to  the  patient,  that  such  an  operation  might  be  quickly  fatal, 
or  prolong  his  life  for  a  few  weeks;  even  with  such  a  slight  hope  he 
most  readily  assented,  so  terrible  was  the  sense  of  starvation  and  of 
thirst.  These  symptoms  were  relieved,  and  the  horrors  of  such  a 
death  partially  mitigated.  In  the  treatment  of  the  case  after  the 
stomach  had  been  opened,  it  might  have  been  well  to  have  repeated 
nutrient  injections  by  the  rectum,  and  to  have  given  food  less  fre- 
quently, although  the  quantity  introduced  at  each  time  was  only 
two  ounces.  There  was  fear  lest  the  operation  might  suddenly  ter- 
minate the  flickering  flame  of  life,  and  lest  no  rallying  should  take 
place;  and  afterwards,  lest  the  sutures  should  give  way,  and  thus 
the  contents  of  the  stomach  be  freely  extra vasa ted  into  the  perito- 
neum. After  twenty-four  hours,  faintness  came  on;  the  patient  was 
evidently  sinking,  and  any  treatment  would  have  been  alike  ineffec- 


ON    DISEASES    OF    THE    (ESOPHAGUS.  99 

tive.  Stimulants  Avere  given  very  freely,  and  at  each  time  were 
followed  by  a  slight  revival  in  the  action  of  the  heart.  There  ap- 
peared to  be  nothing  to  call  for  the  use  of  opium;  at  last,  a  small 
quantity  of  tincture  of  iron  was  administered,  as  being  one  of  the 
most  powerful  stimulants.  The  consideration  of  the  complete  par- 
ticulars of  this  case  leads  to  the  conviction,  that  if  the  operation  had 
been  performed  earlier  more  permanent  benefit  might  have  accrued. 
It  was  done  with  a  comparatively  trifling  addition  to  the  sufferings* 
of  the  patient;  it  was  effected  with  ease,  without  collapse  or  perito- 
nitis; and  the  thirst  and  sense  of  starvation  were  relieved  in  a  degree 
which  were  scarcely  anticipated.  In  cases  of  equally  advanced 
starvation  death  has  ensued  as  quickly;  and  it  is  probable  that  had 
the  operation  not  been  performed,  life  would  have  terminated  even 
more  speedily.  The  patient  would  certainly  have  been  deprived  of 
the  relief  which  for  twenty-four  hours  he  experienced.  Under  these 
circumstances  we  should  strongly  urge  a  repetition  of  this  operation, 
if  a  favorable  case  were  presented,  but  at  an  earlier  period  of  the 
disease. 

Mr.  Forster  has  a  second  time  performed  this  operation  on  a  child 
for  occlusion  of  the  oesophagus  from  the  action  of  caustic  alkali ; 
but  so  feeble  had  the  child  become  that  the  stitches  between  the 
coats  of  the  stomach  and  the  skin  gave  way,  and  extravasation  took 
place  into  the  peritoneal  cavity. 

Since  the  publication  of  my  former  editions,  the  operation  which 
was  attempted  for  the  first  time  to  relieve  obstruction  of  the  oeso- 
phagus by  opening  the  stomach  has  been  performed  many  times, 
and  the  following  table  shows  in  each  instance  the  nature  of  the 
case,  the  duration  of  the  symptoms,  the  length  of  time  that  life 
was  prolonged  after  the  operation,  and  the  cause  of  death. 

During  the  time  that  this  work  has  been  in  the  press,  my  col- 
league, Mr.  Howse,  has '  in  two  cases  successfully  performed  the 
operation  of  opening  the  stomach  ;  in  one  case  a  man  suffering  from 
extensive  cancerous  disease  of  the  oasophagus  survived  a  month ; 
the  patient  was  fed  through  the  parietes,  and  death  was  occasioned 
by  the  extension  of  the  cancerous  disease  and  by  gangrenous  pneu- 
monia. The  second  case  is  still  more  recent  (July,  1878),  but  the 
patient  is  doing  well,  and  the  fistulous  opening  into  the  stomach  is 
well  established. 

Of  seventeen  cases,  then,  all  proved  fatal,  the  greater  proportion 
of  them  succumbing  within  a  few  hours,  and  only  two  surviving 
the  risk  of  the  operation  itself.  One  of  Mr.  Sydney  Jones's  cases 
lived  forty  days  and  died  of  bronchitis.  Another,  under  the  care  of 
the  same  surgeon,  lived  thirteen  days.  One  patient  lived  ten  days 
and  died  of  septicaemia.  Others  only  survived  three  or  four  days. 


100 


ON    DISEASES    OF    THE    (ESOPHAGUS. 


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ON    DISEASES    OF    THE    (ESOPHAGUS.  101 

It  must  be  noted,  however,  that  7  died  of  exhaustion,  and  these 
only  show  that  the  operation  was  done  too  late.  They  tell  very 
little  against  the  operation  itself.  In  three  others  exhaustion  had 
probably  as  much  to  do  with  the  fatal  result  as  the  peritonitis.  One 
patient  died  of  broncho-pneumonia. 

It  is  also  worthy  of  note  that  in  Mr.  Durham's  article  on  Gas- 
trotomy,  seven  cases  of  the  operation  were  performed  for  the  ex- 
traction of  foreign  bodies  and  these  all  recovered. 

Professor  Verneuil1  records  a  successful  case  of  gastrotomy  per- 
formed upon  a  young  man  aged  seventeen,  in  whom  the  cesophageal 
obstruction  was  due  to  the  swallowing  of  caustic  potash.  The  poTson 
was  taken  on  February  4th,  and  the  stomach  was  opened  on  June 
26th.  In  September  he  was  convalescent. 

CASE  XXIII.  Cancer  of  the  (Esophagus.  Sloughing.  Perforation  of 
the  Aorta.  Sudden  and  fatal  Hemorrhage — Margaret  H — ,  aet.  60,  was 
admitted  April  17th,  1861,  under  Dr.  Wilks's  care,  in  a  prostrate  condition  ; 
she  made  no  special  complaint,  but  appeared  to  be  worn  out  from  hard  work, 
rathsr  than  to  be  suffering  from  any  positive  disease.  About  a  fortnight  after 
admission,  she  spat  up  a  little  blood  ;  but,  on  careful  examination  of  the  chest, 
no  disease  could  be  detected.  Two  days  before  death  she  again  spat  up  a 
little  blood,  and  appeared  very  prostrate.  She  rapidly  sank.  On  inspection, 
a  circumscribed  sloughing  cancer  was  found  in  the  centre  of  the  oesophagus  ; 
the  disease  extended  into  the  mediastinum,  and  involved  the  lung  on  the  left 
side.  The  sloughing  had  extended  into  the  aorta ;  the  walls  of  the  vessel 
were  perforated,  and  the  stomach  was  distended  with  blood.  It  could  not  be 
ascertained  that  she  had  ever  suffered  from  dysphagia. 

The  diagnosis  of  this  case  was  very  obscure,  and  even  when  the 
first  oozing  of  blood  came  on  it  was  supposed  to  have  been  poured 
out  from  the  lungs ;  the  hemorrhage  from  the  aorta  led  to  fatal 
syncope ;  the  blood,  however,  passed  downwards  into  the  stomach, 
and  was  not  rejected  by  the  mouth.  The  absence  of  the  dysphagia 
increased  the  obscurity  of  the  symptom. 

Among  other  diseases  of  the  oesophagus  we  may  mention  polypus 
and  muscular  tumors. 

Polypus  at  the  commencement  of  the  (Esophagus.  In  the  'Medico- 
Chirurgical  Transactions'  (vol.  xxx),  a  case  of  this  kind  is  recorded 
by  Dr.  Arrowsmith.  A  lobulated  growth,  freely  movable  and  about 
the  size  of  a  walnut,  was  attached  to  the  mucous  membrane  of  the 
oesophagus,  and  produced  fatal  dysphagia.  The  tumor  was  vascular 
and  homogeneous  in  structure. 

Myomata  of  the  oesophagus  have  been  occasionally  found,  and  an 
interesting  case  of  this  kind  is  minutely  described  in  the  'Trans. 
Path.  Soc.,'  1875,  by  my  colleague  Dr.  Hilton  Fagge.  A  large  tumor, 
two  inches  in  length,  was  found  about  the  centre  of  the  oesophagus, 
in  a  man  aged  thirty-eight.  He  died  from  bronchitis  and  emphy- 
sema and  an  injury  to  the  knee,  but  he  did  not  suffer  from  any  symp- 
tom of  oesophageal  disease. 

Obstruction  of  the  (Esophagus  from  pressure  of  Aneurismal  or  other 
Tumors.  Tumors  of  a  cancerous,  strumous,  or  aneurismal  character, 

'  '  Gaz.  des  Hop.,'  Oct.  28,  1876  ;  '  Med.  Times  and  Gazette,'  Nov.  1876. 


102  ON    DISEASES    OF    THE    (ESOPHAGUS. 

sometimes  exert  pressure  upon  the  oesophagus,  and  cause  dysphagia. 
Cancerous  and  strumous  diseases  of  the  glands  occur  more  frequently 
in  the  anterior  than  in  the  posterior  mediastinum,  and  in  the  former 
situation  they  do  not  exert  pressure  upon  the  oesophagus ;  but  where 
the  root  of  the  lung  or  the  lower  part  of  the  neck  is  involved  there 
is  closer  proximity  with  the  oesophagus,  and  pressure  upon,  or  sup- 
puration communicating  with  the  canal  may  be  the  result. 

The  oesophagus  is  also  in  close  contact  with  the  aorta,  and  we 
frequently  find  that  dysphagia  is  one  of  the  symptoms  of  aneurismal 
disease  of  that  vessel ;  the  dysphagia  is,  however,  less  severe  and 
constant  than  in  direct  constriction  of  the  oesophagus.  It  is  no  un- 
common thing  to  find  death  suddenly  taking  place  from  rupture  of 
the  aneurism  into  the  oesophagus;  but  a  considerable  time  may 
elapse,  as  in  an  instance  recorded  by  Mr.  S.  Cooper,  in  which  eight 
weeks  elapsed  after  the  first  rupture  before  the  fatal  hemorrhage 
occurred;  in  other  instances  death  follows  from  the  condition  of  the 
heart,  or  from  pressure  on  the  respiratory  and  laryngeal  nerves, 
producing  fatal  syncope  or  apnoea,  even  although  the  pressure  on  the 
oesophagus  may  have  been  sufficient  to  produce  sloughing.  As  to 
other  symptoms,  they  are  pain  at  the  sternum,  at  the  side,  between 
the  shoulders,  and  very  frequently  down  the  arm ;  paroxysms  of 
dyspnoea  often  cause  intense  distress;  and  raucedo  from  pressure  on 
the  laryngeal  nerves  is  by  no  means  unfrequent.  The  sounds  of  the 
heart  are  frequently  modified,  and  if  any  pressure  be  exerted  on  the 
bronchus,  it  is  manifested  by  the  less  free  admission  of  air  into  the 
lung  on  the  side  of  the  obstructed  bronchus.  The  pain,  dyspnoea, 
and  dysphagia,  in  some  of  these  cases,  are  much  relieved  when  the 
patient  bends  the  body  forward,  so  as  to  remove  the  pressure  from 
the  structures  beneath.  In  an  instance  mentioned  by  Mr.  Armiger, 
in  the  '  Medico-Chirurgical  Transactions'  (vol.  ii),  the  patient  was 
most  easy  on  his  knees  and  elbows. 

The  diagnosis  is  often  very  obscure ;  the  emaciation  is  not  gene- 
rally so  great  as  we  find  in  cancerous  disease,  but  the  paroxysms  of 
dyspnoea  and  pain  are  more  marked  and  are  exceedingly  severe, 
although  the  patient  is  at  times  able  to  swallow  with  ease.  The 
treatment  is  simply  palliative ;  yet  much  may  be  done  for  the  com- 
fort of  the  patient  and  the  prolongation  of  life,  by  the  regulation  of 
the  diet,  the  avoidance  of  mental  and  physical  excitement,  and  the 
occasional  use  of  sedatives  and  anti-spasmodics,  as  of  morphia,  chloric 
ether,  stramonium,  &c.,  to  relieve  the  paroxysms  of  dj^spnoea.  A 
word  of  caution  must  be  given  in  reference  to  the  use  of  bougies,  for 
I  have  seen  several  instances  in  which  the  attempt  to  pass  a  bougie 
would  have  at  once  broken  down  the  communication  with  the  aneu- 
rismal sac,  and  have  led  to  sudden  fatal  hemorrhage. 

CASE  XXIV.  Aneurism  of  the  Aorta  and  Sloughing  (Esophagus. — James 
F — ,  set.  34,  was  admitted,  November,  1855,  and  died  in  January,  1856 ;  he 
was  a  temperate  man,  married,  and  a  laborer  at  Dartford.  Six  months  before 
his  admission,  after  having  been  engaged  a  short  time  previously  in  carrying 
very  heavy  weights,  he  experienced  pain  in  the  left  breast;  this  pain  became 
much  more  severe,  and  also  extended  between  his  shoulders,  but  there  was 


ON    DISEASES    OF    THE    (ESOPHAGUS.  103 

no  tenderness  in  the  back.  December  4th,  the  pain  at  the  left  nipple  became 
more  fixed,  and  there  was  a  slight  systolic  bruit.  January  1st,  it  was  noticed 
that  the  radial  pulse  was  weaker  on  the  right  side,  and  he  was  found  to  have 
difficulty  in  swallowing  solids.  This  dysphag'a  increased  in  severity,  and 
his  dyspnoea  became  more  distressing.  January  20th,  he  was  unable  to 
swallow  food  ;  his  face  was  livid,  dyspnoea  urgent,  and  his  pain  severe.  He 
died  on  the  25th.  On  examining  the  chest,  the  lungs  were  emphysematous, 
pale,  but  moderately  collapsed.  There  was  acute  inflammation  of  the  peri- 
cardium, and  considerable  injection  of  the  pleura  on  both  sides.  On  turning 
aside  the  lungs,  an  aneurismal  tumor,  about  the  size  of  a  large  orange,  was 
found  at  the  termination  of  the  arch  of  the  aorta ;  its  walls  were  thin ;  the 
posterior  part  of  the  vessel  was  entirely  destroyed,  and  communicated  with  a 
cavity  in  front  of  the  vertebrae,  one  of  which  was  absorbed.  There  was 
scarcely  any  fibrin  in  the  sac.  The  aneurismal  tumor  had  pressed  upon  the 
oesophagus,  and  quite  obliterated  its  canal ;  the  whole  of  its  walls  were  of  a 
greenish  color,  very  offensive,  and  in  a  sloughing  condition.  Still  no  per- 
foration had  taken  place.  Both  bronchi  were  compressed.  Two  other 
aneurismal  tumors  were  found  connected  with  the  ascending  and  transverse 
portions  of  the  arch  of  the  aorta.  Other  viscera  were  healthy. 

CASE    XXV.     Aneurism   of  the  Ascending  Aorta  Rupturing  into  the 

Pericardium.     Communication  of  the  (Esophagus  icith  the  Left  Bronchus 

Frederick  K — ,  get.  23,  was  admitted  under  Sir  William  Gull's  care,  January 
23d,  and  died  April  26th,  1856.  He  was  a  hawker,  and  had  been  living  in 
the  Old  Kent  Road  ;  he  had  enjoyed  good  health  till  five  months  previously, 
when  he  struck  his  chest  against  a  box  hanging  from  a  crane ;  a  fortnight 
afterwards  he  experienced  pain  at  the  part ;  this  gradually  increased  till  three 
weeks  before  admission,  when  he  was  obliged  to  give  up  work.  On  admission, 
he  complained  of  pain  in  the  chest ;  a  distinct  pulsation  could  be  felt  between 
the  second  and  third  ribs  on  the  right  side,  and  a  jar  with  the  second  sound 
of  the  heart.  There  was  pain  at  the  seat  of  pulsation,  and  along  the  border 
of  the  pectoralis  major,  and  down  the  inner  side  of  the  arm.  The  pain  con- 
tinued severe,  and  a  systolic  bruit  became  audible  at  the  seat  of  the  tumor. 
He  could  obtain  no  rest  at  night.  On  April  19th,  he  had  difficulty  in  swal- 
lowing, and  this  symptom  increased  in  severity.  On  the  28th,  after  talking 
witli  his  friends,  he  died  very  suddenly.  On  removing  the  sternum,  an  aneu- 
rism of  the  ascending  aorta  was  opened  ;  it  had  extended  to  the  sternum  oil 
the  right  side.  On  opening  the  pericardium,  it  was  discovered  to  be  full  of 
blood,  and  a  small  irregular  communication  was  found  at  its  upper  part  with 
the  aorta.  The  heart  was  of  normal  size ;  the  left  ventricle  was  not  hyper- 
trophied  ;  the  valves  were  healthy.  The  ascending  aorta  formed  an  aneuris- 
mal sac,  about  two  inches  and  a  half  in  diameter,  principally  on  the  right 
side.  The  lung  was  adherent,  and  it  was  nearly  perforated.  The  aneurism 
extended  as  far  as  the  origin  of  the  left  carotid  ;  below  the  left  subclavian  was 
another  small  dilatation.  At  the  centre  of  the  oesophagus  was  a  slough,  and 
an  opening  had  been  formed  into  the  left  bronchus ;  there  was  no  communi- 
cation, however,  with  the  aorta.  The  remaining  viscera  were  healthy. 

Although  it  appeared  that  the  greater  pressure  from  the  aneurism 
was  on  the  right  rather  than  on  the  left  side,  we  can  find  no  other 
explanation  for  this  sloughing  condition  of  the  oesophagus,  and  its 
communication  with  the  bronchus,  beyond  the  pressure  which  all 
these  parts  suffered  from  the  distended  aneurismal  sac. 

CASE  XXVI.     Aneurism.     Pressure  on  the  (Esophagus  and  on  the  Left 


104  OX    DISEASES    OF    THE    (ESOPHAGUS. 

Bronchus.  Difficulty  in  Deglutition,  Sudden  Death — James  F — ,  jet. 
about  40,  was  admitted,  under  Dr.  Addison's  care,  August  24th,  1859,  and 
died  September  24th,  at  f>  P.  M.  He  was  a  spare  man,  pale,  but  strongly 
built ;  for  nine  months  he  had  suffered  from  pain  at  the  sternum  and  between 
the  shoulders ;  he  had  lost  flesh  ;  and  for  several  months  had  suffered  from 
difficulty  in  deglutition,  so  that  on  admission  he  was  unable  to  take  solid  food  ; 
but  fluids  were  easily  swallowed.  A  few  days  after  he  had  been  in  the  hos- 
pital, an  attack  of  very  urgent  dyspnoea  came  on,  but  gradually  subsided, 
leaving  the  respiration  easy  and  of  ordinary  frequency.  Jn  that  state  he 
remained  till  the  day  of  his  death.  The  physical  signs  were  obscure  ;  the 
resonance  on  the  left  side  was  very  slightly  diminished  ;  the  respiratory  sounds 
on  that  side  were  much  less  distinct  than  on  the  right ;  and  were  accompanied 
at  the  base  with  slight  mucous  rales;  the  voice  was  not  increased  in  resonance. 
Jso  abnormal  pulsation  nor  sound  in  the  interscapular  or  sternal  regions  could 
be  heard.  The  heart  sounds  were  normal  as  to  rhythm;  but  the  second  sound 
was  "ringing ;"  the  pulse  was  compressible,  more  feeble  on  the  left  side.  He 
had  no  vomiting,  neither  was  there  any  evidence  of  enlarged  glands  in  the 
neck,  &c.,  nor  had  he  any  pain  in  the  arm.  On  the  24th,  after  taking  his 
tea,  he  washed  up  the  things  for  the  nurse,  and  immed'ately  afterwards  he 
was  seen  sitting  on  the  edge  of  his  bed,  unable  to  speak,  and  scarcely  able  to 
breathe.  He  never  spoke  afterwards,  but  died  in  about  a  quarter  of  an  hour, 
the  heart  continuing  to  beat  after  he  had  ceased  to  breathe.  On  inspection. — 
About  one  inch  below  the  left  subclavian  artery  an  oval  opening,  with  rounded 
edges,  led  from  the  aorta,  into  a  large  aneurismal  cavity  about  four  inches  in 
diameter ;  this  cavity  was  bounded  posteriorly  by  the  vertebrae,  which  were 
corroded;  the  tumor  pressed  upon  the  left  bronchus,  and  upon  the  oesophagus, 
and  probably  upon  the  thoracic  duct.  The  lungs  were  healthy.  The  bronchi 
on  the  left  side  were  rather  more  congested  than  usual.  The  ascending  aorta 
and  the  arch  were  atheromatous ;  the  valves  and  the  muscular  fibre  of  the 
heart  were  healthy ;  the  pericardium  was  normal,  and  no  disease  could  be 
found  in  any  other  part. 

The  sudden  fatal  apncea  was  due,  probably,  either  to  injury  of  the 
laryngeal  nerves  and  spasmodic  action  of  the  larynx ;  or  to  sudden 
distension  and  increased  pressure  on  the  bronchus.  The  diagnosis 
was  very  obscure  ;  the  symptoms  were  slight,  and  the  interference 
with  the  entrance  of  air  into  the  left  lung  might  have  been  regarded 
as  arising  from  a  tumor  in  the  mediastinum. 

CASE  XXVII.  Dissecting  Aneurism  of  the  Aorta  bursting  into  the  (Esoph 
af/us — James  H — ,  jet.  38,  had  been  losing  flesh  before  admission,  but  origi- 
nally had  been  a  very  muscular  man.  He  had  suffered  from  symptoms  of 
dysphagia,  and  there  was  crepitation  at  the  base  of  one  lung.  The  aortic 
arch  was  found  to  be  in  a  very  diseased  state.  There  were  two  true  aneu- 
risms, one,  the  size  of  a  hazel-nut,  would  allow  the  tip  of  the  finger  to  pass 
into  it,  and  was  situated  opposite  the  orifice  of  the  left  subclavian  ;  at  the 
posterior  part  of  the  aorta  was  a  second  as  large  as  a  plum  ;  this  opened 
straight  into  the  oesophagus  by  a  perforation  capable  of  admitting  three  fingers, 
and  the  blood  had  passed  downwards  in  the  coats  of  the  oesophagus,  separating 
the  mucous  from  the  submucous  coats  as  far  as  the  stomach.  The  muscular 
fibres  were  hypertrophied ;  and  the  stomach  and  half  the  intestine  were  full 
of  blood. 

Mediastinal  tumors  and  enlarged  ylands   may  cause  obstruction. 


OX    DISEASES    OF    THE    (ESOPHAGUS.  105 

These  may  be  of  variable  nature.  All  primary  mediastinal  tumors 
may  be  said  to  be  lymphomata ;  but  other  diseases  occasionally 
occur,  and  of  these  may  be  mentioned  a  fibrous  growth  of  gumma- 
tous  nature,  which  has  been  found  twice  in  our  post-mortem  series. 
At  other  times  some  extension  of  cancer  from  the  oesophagus  may 
lead  to  more  complete  obstruction,  or  hydatid  tumors  may  occasion- 
ally cause  the  same  symptoms. 

In  a  man  set.  -W,  admitted  with  a  large  cancerous  mass  in  the  neck 
on  the  left  side,  the  growth  evidently  extended  into  the  chest,  and  he 
soon  suffered  from  difficulty  in  breathing.  The  disease  had  passed 
down  the  oesophagus  beneath  the  mucous  membrane,  and  it  formed 
a  thick  external  layer;  about  the  bifurcation  of  the  trachea  the  whole 
canal  was  involved.  The  bronchial  glands,  and  also  the  kidneys, 
were  affected.  The  lungs  were  in  an  early  stage  of  pneumonia. 

Before  concluding  the  subject  of  dysphagia,  I  must  refer  to  its 
occasional  presence  in  pericarditis,  and  pleuro-pneumonia,  as  men- 
tioned by  Dr.  Stokes,  in  his  valuable  work  on  '  Diseases  of  the  Heart.' 
Although  very  numerous  instances  of  these  diseases  have  come  under 
my  observation,  I  do  not  remember  ever  having  witnessed  difficulty 
in  swallowing  associated  with  the  other  symptoms  of  pericarditis ; 
and  even  when  the  pericardium  was  found  distended  with  36  oz.  ot 
pus,  and  nearly  filled  the  left  side  of  the  chest,  this  symptom  was 
not  observed;  in  a  patient  recently  under  my  care,  extensive  pleuritic 
effusion  was  found  with  dysphagia,  but  careful  investigation  led  me 
to  believe  that  the  latter  symptom  had  its  origin  in  local  disease. 
Transient  enlargement  of  the  bronchial  glands  might,  however,  in- 
duce the  dysphagia  in  these  cases,  and,  to  quote  the  words  of  Dr. 
Stokes,  it  may  probably  "be  less  the  result  of  a  mechanical  condition, 
such  as  pressure  on  the  oesophagus,  than  of  some  excited  irritability 
either  of  that  tube,  or  of  parts  immediately  in  contact  with  it." 

.VII.  Dysphagia  from  destruction  of  the  mucous  membrane  by  mechani- 
cal or  chemical  agents. 

Every  year  the  lives  of  many  children  are  destroyed  by  drinking 
boiling  water;  vesication  of  the  mouth,  fauces,  and  pharynx  is  at 
once  produced;  but  generally,  the  instantaneous  rejection  of  the 
scalding  fluid  prevents  any  portion  from  being  swallowed.  The 
margin  of  the  epiglottis  and  the  entrance  of  the  larynx  are,  however, 
often  injured,  and  the  sudden  swelling  of  the  mucous  membrane  of 
the  glottis  by  preventing  the  entrance  of  air  into  the  lungs,  leads  to 
a  rapidly  fatal  result. 

The  prognosis  after  accidents  of  this  kind  in  infants  is  very  un- 
favorable ;  for,  although  the  respiration  may  be  apparently  unimpeded 
several  hours  after  the  injury,  a  slight  increase  of  effusion  of  serum 
into  the  swollen  mucous  membrane  of  the  larynx  leads  to  complete 
occlusion  of  the  already  diminished  rima,  and  causes  death  from 
apnoea.  The  operation  of  tracheotomy  has  in  not  a  few  instances 
saved  life,  but  in  many  the  supervention  of  acute  disease  of  the 
trachea  and  bronchi  has  proved  quickly  fatal.  In  several  inspections 
after  death,  the  mucous  membrane  of  the  lower  part  of  the  oesoph- 
agus and  stomach  have  presented  considerable  congestion,  showing 


106  ON    DISEASES    OF    THE    (ESOPHAGUS. 

that  some  of  the  hot  water  Lad  reached  those  parts;  and  in  a  case 
of  poisoning  by  corrosive  sublimate,  lymph  was  found  in  the  oesoph- 
agus. 

The  action  of  corrosive  poisons  may  be  divided  into  that  which  is 
immediate  or  primary,  and  that  which  is  remote  or  secondary.  The 
mucous  membrane  of  the  mouth,  fauces,  pharynx,  and  oesophagus, 
becomes  at  once  discolored  by  the  chemical  action  of  the  poison,  and 
it  assumes  a  yellowish-white  or  brown  color,  according  to  the  strength 
and  character  of  the  agent;  if  the  poison  be  in  a  very  concentrated 
state,  the  membrane  is  charred  and  destroyed.  The  effusion  of  a 
sero-alburninous  fluid  into  the  mucous  membrane,  or  into  the  cellular 
tissue,  leads  to  considerable  swelling;  but,  as  with  boiling  water,  the 
epiglottis  rarely  escapes  injury,  and  its  margin  often  presents  an 
eroded  and  serrate  appearance.  The  longitudinal  rugae  of  the  oesoph- 
agus, especially  near  the  stomach,  are  discolored  or  destroyed;  shreds 
of  cesophageal  membrane  are  sometimes  ejected,  and  in  one  instance,1 
after  strong  sulphuric  acid  had  been  taken,  a  complete  cast  of  the 
oesophagus  was  thrown  off.  The  stomach  also  is  sometimes  exten- 
sively injured,  its  mucous  membrane  and  coats  being  charred,  or  even 
perforated,  and  the  adjoining  viscera  similarly  acted  upon  wherever 
the  poison  comes  in  contact  with  them.  If  the  patient  survive  the 
immediate  action  of  the  poison,  a  fibro  plastic  product  is  effused  into 
the  submucous  tissue;  thickening  and  contraction  of  the  new  product 
takes  place,  and  in  this  manner  an  annular  constriction  may  arise. 

Symptoms. — The  first  symptom  produced  by  taking  corrosive 
poison  is  severe  pain  of  a  burning  character  in  the  mouth  and  throat, 
and  along  the  whole  tract  of  the  oesophagus.  When  any  portion  has 
been  swallowed  it  is  succeeded  by  vomiting  of  dark  colored  fluid, 
containing  blood ;  extreme  dysphagia  quickly  follows,  and  the  act  of 
speaking  is  exceedingly  painful;  there  is  also  sometimes  urgent 
dyspnoea.  The  lips  are  often  injured  by  the  contact  of  the  poison, 
the  tongue  is  found  to  be  swollen  and  injected,  arid  the  mucous  mem- 
brane of  the  whole  mouth  is  discolored,  becoming  yellowish-white  or 
brown,  or  completely  charred;  and  the  throat  is  in  a  similar  condi- 
tion. Cough  and  dyspnoea  are  distressing  symptoms  if  the  epiglottis 
and  larynx  have  been  injured.  Diarrhoea  is  occasionally  present. 
The  patient  has  an  anxious  and  dejected  countenance ;  the  pulse  is 
compressible  and  feeble ;  but  the  mind  retains  consciousness  till  death, 
which  may  take  place  in  a  few  hours.  In  other  cases,  it  is  often 
remarkable  how  soon  the  injured  mucous  membrane  of  the  mouth 
and  throat  recover  themselves;  the  vomiting  subsides;  the  extreme 
pain  in  the  throat  produced  by  swallowing  or  coughing  disappears; 
and  in  a  few  days  the  patient  appears  almost  convalescent,  and  gives 
hope  of  recovery.  If  only  the  mucous  membrane  of  the  stomach 
be  injured,  there  may  be  entire  immunity  from  pain ;  but  the  freedom 
from  pain  is  a  very  deceptive  symptom,  the  patient  often  unexpect- 
edly dies,  from  syncope  or  asthenia,  although  more  generally  the 
subsequent  contraction  of  the  inflammatory  product  in  the  oesoph- 
agus, stomach,  or  pylorus,  leads  to  obstruction,  slow  emaciation, 

1  Mayo's  '  Outlines  of  Pathology.' 


OX    DISEASES    OF    THE    (ESOPHAGUS.  107 

the  regurgitation  or  vomiting  of  food,  and  a  lingering  death  from 
inanition. 

The  first  effect  of  these  poisonous  agents  is  best  combated  by  the 
use  of  substances  capable  of  neutralizing  their  chemical  properties, 
combined  with  oleaginous  and  demulcent  drinks  to  shield  the  mucous 
membrane.  Opiates  may  be  given  to  relieve  pain,  and  as  soon  as 
deglutition  can  be  performed,  bland  and  nutritious  diet  may  be 
allowed. 

When  secondary  contraction  of  the  oesophagus  has  taken  place 
the  probability  of  relief  is  slight;  fluid  forms  of  nutriment  adminis- 
tered in  a  concentrated  form,  and  injections  of  a  similar  kind  may 
prolong  life.  Dr.  Cumin1  succeeded  in  saving  the  life  of  a  child  by 
the  use  of  elastic  catheters,  after  potash  had  been  taken;  and  Mr. 
Forster,2  after  the  same  poison,  sought  a  like  result,  though  less  suc- 
cessfully, by  the  formation  of  a  gastric  fistula. 

CASE  XXVIII.     Poisoning  by  Sulphuric  Acid.    Death  on  the  llth  day 

In  an  interesting  case  of  poisoning  by  sulphuric  acid,  in  October,  1855,  in 
which  death  did  not  take  place  until  the  eleventh  day,  the  mouth  and  throat 
were  of  a  whitish  color;  at  the  posterior  part  of  the  mouth,  there  was  con- 
siderable injection  of  the  mucous  membrane,  and  on  each  side  of  the  posterior 
pillar  of  the  fauces  there  were  whitish  loose  patches  of  membrane.  The 
edge  of  the  epiglottis  was  found  minutely  eroded,  and  the  mucous  membrane 
of  the  oesophagus  was  pale  and  covered  with  yellow  membranous  flakes.  The 
prostration  and  collapse  immediately  following  the  reception  of  the  poison 
were  accompanied  by  vomiting  of  grumous  blood,  but  in  less  than  twelve 
hours  the  patient  was  able  to  swallow  some  milk  and  arrowroot ;  and  on  the 
fourth  day  appeared  to  take  her  food  without  difficulty.  Death  took  place 
from  the  sloughing  condition  of  the  mucous  membrane  of  the  stomach,  com- 
bined with  inflammation  of  the  duodenum,  and  of  the  whole  tract  of  the 
intestine.  The  ability  to  swallow  in  this  case  was  restored  in  a  very  short 
time,  considering  the  fearful  injuries  which  resulted  to  the  whole  of  the 
mucous  membrane.  (See  more  lull  account  of  the  state  of  the  stomach  in 
our  remarks  on  that  viscus.) 

Two  instances  admitted  into  Guy's  Hospital  in  1857,  illustrate  the 
primary  effects  of  poisons  on  the  pharynx  and  oesophagus.  They 
are  detailed  in  the  Reports  for  1859,  by  Dr.  Wilks: 

CASE  XXIX.  "Poisoning  by  Soap-Lees — Charles  T.  C — ,  set.  a  year 
and  a  half,  was  admitted  under  Mr.  Hilton,  on  September  4th,  1857,  at  six 
o'clock  in  the  evening.  About  an  hour  before,  the  child  had  drunk  from  a 
cup  about  a  mouthful  of  soap-lees ;  some  oil  and  mucilaginous  fluids  were 
administered,  and  he  was  brought  to  the  hospital.  The  child  was  then  very 
ill,  and,  in  the  course  of  an  hour  or  two,  some  difficulty  of  breathing  came  on, 
but  this  did  not  appear  sufficiently  extreme  to  warrant  tracheotomy.  The 
most  marked  symptom  after  this  was  an  intense  heat  of  skin.  The  child  died 
at  five  o'clock  on  the  following  morning,  twelve  hours  after  swallowing  the 
fluid. 

"  Post-mortem  appearances — The  mouth  and  tongue  were  slightly  exco- 
riated, and  of  a  light  brown  color.  The  fauces,  tonsils,  and  mucous  membrane 
of  the  pharynx  had  a  slightly  swollen  appearance,  and  had  a  yellowish-brown 

1  '  Transactions  of  the  Medical  and  Chir.  Soc.  Edin.' 
*  'Guy's  Hcwpital  Reports.' 


108  ON    DISEASES    OF    THE    03SOPHAGUS. 

hue.  The  whole  of  the  oesophagus  presented  a  similar  condition,  the  mucous 
membrane  having  a  brownish  color,  particularly  the  longitudinal  rugte.  The 
membrane  was  changed  in  character  by  the  alkali,  but  was  nowhere  destroyed. 
Tin'  most  pernicious  effect  had  been  produced  at  the  very  extremity  of  the 
oesophagus,  where  the  interior  was  of  a  dark-brown  color;  this  terminated  at 
a  defined  line,  the  mucous  membrane  of  the  stomach  immediately  below  being 
quite  unaffected.  The  stomach  was  contracted.  It  was  found  on  opening  it 
to  be  quite  empty;  the  ruga?,  were  well  marked,  and  the  whole  mucous  mem- 
brane had  a  slightly  pink  hue,  being  more  than  usually  injected.  These 
appearances  were,  however,  so  slight  that,  unless  especially  looked  for, 
they  would  probably  have  been  disregarded.  As  before  stated,  the  ter- 
mination of  the  oesophagus  was  of  a  dark  brown  color,  but  this  terminated 
abruptly  at  its  margin.  Towards  the  pyloric  end  of  the  stomach,  near 
its  greater  curvature,  there  were  a  few  rugae  of  a  very  dark  color,  produced, 
no  doubt,  by  the  action  of  the  alkali.  The  mucous  membrane,  thus  altered, 
was  not  at  all  soft,  nor  could  it  be  stripped  off;  but,  on  the  contrary,  was  hard, 
and  had  a  horny  feel.  The  duodenum  was  healthy.  The  larynx,  at  its  top, 
was  almost  closed  by  the  greatly  swollen  epiglottis,  the  enlargement  being  due 
to  an  effusion  of  serum  within  it ;  the  glottis  itself  was  only  slightly  swollen  ; 
and  upon  raising  the  epiglottis  and  looking  into  the  larynx,  the  passage  was 
seen  to  be  quite  free;  neither  the  vocal  cords,  nor  any  other  part,  having  been 
touched.  The  lungs  showed  some  lobules  in  the  first  stage  of  inflammation. 
The  heart  was  healthy,  and  firmly  contracted." 

CASE  XXX.  "  Poisoning  by  Sulphuric  Acid. — William  V — ,  ret.  56. 
The  patient's  mind  was  not  perfectly  sound,  and,  therefore,  the  account  he 
gave  of  himself  was  received  with  some  doubt.  When  he  was  admitted,  on 
the  evening  of  October  28th,  1856,  he  walked  up  stairs  to  his  bed,  and  did 
not  appear  very  ill,  although  he  was  dejected,  and  did  not  speak  much.  He 
stated  that  he  had  been  to  a  friend's  house ;  and  there,  by  mistake,  drank 
about  a  dessert-spoonful  of  oil  of  vitriol.  His  mouth  was  of  a  brown  color, 
but  not  excoriated.  Magnesia  and  milk  were  given  him.  On  the  following 
day,  and  also  on  the  third,  he  appeared  depressed ;  but  he  was  not  otherwise 
ill,  and  it  was  thought,  from  the  mildness  of  the  symptoms,  that  he  would 
recover.  On  the  fourth  day,  however,  he  died  rather  suddenly,  or,  at  least, 
unexpectedly. 

"  Post-mortem  examination. — The  body  was  that  of  a  strong,  muscular 
,man.  A  yellow  fluid,  of  acid  reaction,  ran  from  the  mouth.  The  brain  was 
not  quite  healthy.  The  mucous  membrane  of  the  mouth  was  of  a  yellow 
color,  but  when  this  yellow  epithelial  layer  was  removed,  the  mucous  membrane 
left  was  healthy.  The  front  part  of  the  tongue  was  also  discolored,  but  not 
the  back.  The  ossophagus  throughout  was  of  a  yellow  color.  The  mucous 
membrane  was  only  affected  in  the  most  prominent  ridges,  but  the  walls  of 
the  organ  were  swollen  to  three  times  their  natural  thickness.  This  was  due 
to  a  sero-albuminous  exudation  into  the  submucous  tissue.  The  top  of  the 
larynx  was  also  slightly  swollen  in  the  same  manner.  The  stomach  appeared 
natural  externally,  and  was  of  usual  size.  Upon  opening  it,  it  was  found  to 
contain  about  a  pint  of  a  bright  yellow  fluid.  The  mucous  membrane  was 
especially  affected  at  the  pyloric  half  of  the  stomach.  The  fundus,  in  which 
the  fluid  was  found  lying  as  usual,  had  only  a  yellow  tint  like  the  oesophagus, 
and  the  mucous  membrane  was  softened ;  but,  towards  the  middle  of  the 
stomach,  the  whole  of  the  pyloric  half  of  the  interior  was  of  a  black  color, 
and  raised  up  in  projecting  masses  or  ridges,  which  were  in  a  sloughing  con- 
dition, and  would  soon  have  been  cast  off.  This  black  matter  consisted  of  car- 


ON    DISEASES    OF    THE    (ESOPHAGUS.  109 

bonized  and  decomposed  mucous  membrane,  with  blood  within  it.  The  whole 
coats  of  the  stomach  were  soft,  and  readily  tore.  The  charring  of  the  stomach 
ended  at  the  pylorus,  but  about  two  inches  of  the  duodenum  were  of  a  purplish 
color,  ;md  the  rugae  were  blackened  ;  below  this,  the  intestines,  both  small 
and  large,  were  unaffected.  The  small  contained  a  yellow  matter,  similar  to 
that  in  the  stomach.  The  contents  of  the  stomach  were  not  acid,  nor  was 
any  of  the  poison  discoverable.  The  heart  was  healthy,  and  contained  a  firm, 
decolorized  fibrinous  clot  on  the  right  side,  not  acid  in  its  reaction." 

The  following  case  illustrates  the  secondary  effect  of  a  corrosive 
poison  in  the  thickening  of  the  whole  of  the  oesophagus  and  ob- 
structed pylorus,  which  led  to  a  fatal  termination,  in  a  man  who  died 
three  months  after  having  taken  an  ounce  of  nitric  acid. 

CASE  XXXI.  Poisoning  by  Nitric  Acid — James  T — ,  aet.  24,  was 
admitted  under  Dr.  Barlow's  care,  in  March,  1852,  in  a  state  of  extreme 
emaciation  ;  more  than  two  months  previously  he  had  taken  about  an  ounce 
of  nitric  acid,  and  had  completely  swallowed  it  before  he  discovered  the  fatal 
mistake.  The  primary  effects  gradually  subsided,  but  vomiting  after  food 
increased,  and  he  steadily  lost  flesh  and  strength;  he  vomited,  with  some 
pain,  all  the  food  which  he  swallowed;  the  abdomen  sometimes  became  ex- 
tremely distended;  the  bowels  had  only  been  opened  twice  during  the  two 
months  preceding  his  admission;  the  tongue  was  injected.  He  lived  eighteen 
days  after  admission.  On  inspection,  the  epiglottis  appeared  healthy;  the 
mucous  membrane  of  the  whole  of  the  oesophagus  was  thickened  and  readily 
separated  ;  the  submucous  tissue  and  all  the  coats  of  the  oesophagus  were  also 
thickened  ;  the  stomach  was  enormously  distended,  reaching  to  the  anterior 
superior  spinous  process  of  the  pubes;  the  pylorus  was  obstructed,  thickened, 
and  contracted ;  the  lungs  and  heart  were  healthy ;  the  liver  was  small,  deep 
in  color,  and  the  gall-bladder  contained  about  siss  of  dark-colored  bile;  no 
other  viscus  was  diseased. 

CASE  XXXII.  Poisoning  by  Nitric  Acid.  Recovery  from  the  Primary 
Effects. — A  young  man,  set.  about  22,  a  hawker,  whilst  at  his  tea,  on  March 
13th,  took  by  mistake  for  vinegar,  a  mouthful  of  nitric  acid,  and  swallowed 
it.  A  severe  burning  pain  in  the  mouth  was  at  once  produced,  which  ex- 
tended to  the  epigastrium.  A  druggist  prescribed  an  emetic ;  vomiting  then 
came  on,  and  he  brought  up  about  half  a  cupful  of  blood.  The  vomiting 
continued  through  the  night,  and  on  the  following  day  he  was  brought  to 
Guy's;  the  countenance  was  anxious;  the  mouth  and  tongue  were  stained  of 
a  yellow  color,  the  tongue  enlarged  and  injected ;  the  throat  was  intensely 
injected,  and  presented  irregular  shreds  of  whitish  membrane  upon  it.  He 
was  unable  to  swallow,  and  speaking  produced  cough  and  much  distress  in 
the  throat.  He  stated  that  he  suffered  pain  in  the  throat  and  epigastrium 
when  retching  came  on,  but  not  when  quiet.  He  was  a  muscular  man,  and 
in  health  at  the  time  of  the  accident.  Milk  and  eggs  were  given,  and  mag- 
nesia mixture  with  tincture  of  opium  n^v  every  four  hours.  On  the  17th, 
he  was  sitting  up,  taking  food,  and  he  stated  that  he  felt  much  more  com- 
fortable; he  had  slight  pain  in  the  throat  when  he  swallowed,  but  had  no 
other  discomfort.  The  throat  was  still  very  much  injected,  and  sloughy 
mucous  membrane  was  separating.  In  a  few  days  he  left  the  hospital,  and 
considered  himself  well. 

The  immediate  effects  of  the  poison  were  in  a  few  days  relieved, 
and  the  dysphagia  disappeared ;  but  after  such  severe  injury  to  the 
oesophagus  we  must  look  with  great  anxiety  to  the  result,  for  thick- 


110  ON    DISEASES    OF    THE    (ESOPHAGUS. 

ening  of  the  coats  and  constriction  may,  and  perhaps  will,  follow  ; 
in  this  case  the  acid  probably  reached  the  stomach,  for  pain  was 
produced  at  the  scrobiculus  cordis ;  but  there  was  no  evidence  that 
serious  injury  had  been  done  to  that  viscus. 

We  have  already  alluded  to  the  great  frequency  of  organic  stric- 
ture after  corrosive  poisons. 

CASE  XXXIII.  Poisoning  by  Strong  Solution  of  Ammonia — The  pa- 
tient was  sulmittetl  under  the  care  of  my  colleague.  Dr.  Pye-Smith.  On  in- 
spection the  mucous  membrane  of  the  mouth  was  red,  and  glazed  with  shreddy 
mucus.  The  oesophagus  was  intensely  red  in  its  whole  length,  more  especially 
at  its  lower  part,  which  was  of  a  dark  purple,  and  the  color  ceased  abruptly 
at  the  termination  of  the  oesophagus  in  the  stomach;  at  the  upper  part  of  the 
oesophagus  the  mucous  membrane  was  shreddy  in  longitudinal  bands.  The 
stomach  was  injected  over  a  circular  patch,  four  inches  in  diameter,  in  the 
position  where  the  alkali  would  first  impinge  on  the  membrane ;  at  that  part 
the  mucous  membrane  was  thin,  elsewhere  thick,  pale,  and  coated  with  thick 
mucus. 

Obstruction  by  foreign  bodies  does  not  generally  come  under  the 
cognizance  of  the  physician,  but  he  should  bear  in  mind  the  possi- 
bility of  dysphagia  arising  from  such  a  cause,  and  also  that  severe 
and  even  fatal  symptoms  may  result  from  the  swallowing  and  lodg- 
ment of  sharp  substances.  Recorded  cases  seem  to  show  that  of  all 
things  most  commonly  lodging  in  the  oesophagus,  plates  of  artificial 
teeth  are  the  most  frequent.  Such  cases  as  these  are  to  be  found  in 
the  medical  journals.1  That  they  should  cause  obstruction  is  by  no 
means  to  be  wondered  at.  Still  more  remarkable,  however,  is  the 
fact  that  occasionally  large  substances  may  become  impacted  and 
remain  undiscovered  for  a  length  of  time.8  Other  cases  of  dysphagia 
arise,  not  unfrequently,  from  the  lodgment  of  some  pointed  fragment 
of  food,  it  may  probably  be  a  fish  bone.  If  these  foreign  bodies 
remain  they  are  by  no  means  harmless.  Cases  are  scattered  through- 
out medical  literature  in  which  the  points  of  such  sharp  bodies  have 
perforated  the  oesophagus  and  aorta,  and  have  led  to  fatal  hemor- 
rhage. It  is  well  to  remember,  however,  that  many  persons  after 
swallowing  a  bone  may  suppose  that  it  is  still  in  the  throat  when 
they  are  only  suffering  from  the  effects  of  its  passage,  and  a  mere 
abrasion  on  the  surface  of  the  mucous  membrane  will  keep  up  the 
sensation  for  many  days. 

The  treatment  of  such  cases  may  be  left  to  the  surgeon  without 
further  consideration. 

Eccliymosis. — Hemorrhage  from  the  oesophagus  generally  arises 
from  the  rupture  of  aneurismal  tumors,  or  from  cancerous  disease ; 
but  in  cases  of  fatal  purpura,  we  sometimes  find  the  whole  mucous 
membrane  covered  by  points  of  eft  used  blood,  and  blood  is  also 
effused  into  the  surrounding  cellular  tissue.  The  oesophagus,  how- 
ever, is  affected  only  in  common  with  the  whole  mucous  surface  of 
the  alimentary  canal,  as  well  as  with  other  membranes  and  glaiid- 

1  '  Lancet,'  vol.  i,  71 ;  vol.  ii,  73,  &c. 

*  M.  Duplay,  '  Lancet,'  1847.     Vol.  ii,  p.  849. 


ON    DISEASES    OF    THE    (ESOPHAGUS.  Ill 

structures.  The  oesophageal  veins  have  been  found  to  be  varicose 
in  some  cases  of  cirrhosis ;  and  in  a  case  of  hemorrhagic  variola  the 
mucous  membrane  was  found  coated  with  blood. 

The  following  case  warrants  the  belief  that  rupture  of  the  coats  of 
the  cesophagus  sometimes  takes  place  during  life  :  the  specimen  is  in 
the  Museum  of  Guy's  (No.  179946). 

CASE  XXXIV.  Rupture  of  the  (Esophagus — M.  C — ,  set.  24,  a  cabinet 
maker,  of  intemperate  habits,  attended  a  public  supper  in  September,  1842  ; 
during  supper  he  felt  sick,  and  left  the  table;  he  vomited  slightly,  and  re- 
turned home  with  assistance.  He  then  took  a  dose  of  castor  oil ;  at  two  in 
the  morning  he  complained  of  severe  pain  across  the  epigastrium,  and  great 
difficulty  in  breathing  ;  the  abdominal  muscles  rigid,  the  respiration  laborious  ; 
the  patient  was  found  sitting  up  in  bed,  leaning  forwards  on  his  hands ;  his 
countenance  was  anxious,  the  pulse  soft,  the  bowels  had  not  acted  ;  an  emetic 
of  antimony  and  ipecacuanha  was  administered,  but  without  effect ;  at  7.30 
A.  M.  there  was  less  pain,  but  increased  dyspnoea,  and  there  was  emphysema 
of  the  face  and  throat.  The  stomach-pump  was  used,  but  without  effect,  and 
he  died  at  noon.  On  inspection  a  large  rent  was  found  in  the  cesophagus  at 
its  lower  part,  filled  with  ingesta,  which  were  also  extravasated  into  the  left 
pleura ;  the  pleura  also  contained  castor  oil.  The  stomach  and  intestines 
were  exceedingly  distended  with  flatus  ;  and  the  stomach  partially  dissolved 
by  gastric  juice.  The  rent  in  the  resophagus  appears  in  the  preparation  to 
extend  into  the  stomach,  but  perhaps  increased  after  death. 

It  is  probable  that  the  oesophagus  was  much  dilated  with  food, 
and  that  its  coats  were  softened  either  by  previous  disease,  or  by 
digestion  from  gastric  juice  regurgitated  into  it  from  the  stomach, 
and  there  remaining  sufficiently  long  to  corrode  its  walls.  There  is 
no  evidence  that  the  stomach-pump  increased  the  rent,  for  the  castor 
oil  which  was  found  in  the  pleura  was  taken  several  hours  before 
the  stornach-pump  was  used;  still,  if  it  had  been  known  that  such  a 
rent  had  existed,  this  remedy  would  not  have  been  applied ;  the 
severity  of  the  symptoms  suggested  the  probability  that  some 
poisonous  substance  might  have  been  taken  with  the  food,  and  that 
hence  the  emetic  failed  to  act ;  under  such  circumstances  the  use 
of  the  stomach-purnp  would  have  tended  to  relieve  rather  than 
aggravate  the  symptoms. 

Mayo  quotes  a  case  from  Boerhaave  of  rupture  of  the  cesophagus 
after  an  emetic  had  been  taken  by  a  robust,  but  gouty  man  ;  a  rent 
one  and  a  half  inches  in  length  was  found  communicating  with  the 
left  pleura ;  and  the  fatal  result  took  place  twelve  hours  after  the 
emetic  had  been  administered. 

In  a  patient  admitted  in  July,  1874,  under  the  care  of  my  colleague, 
Mr.  Durham,  for  injury,  by  which  the  rib  was  fractured,  the  cesopha- 
gus was  lacerated  for  more  than  an  inch  in  extent.1 

Gastric  Solution. — In  studying  the  diseases  of  the  oesophagus, 
gastric  solution  of  its  lower  extremity  must  be  borne  in  mind.  This 
has  been  very  clearly  brought  forward  in  the  communications  to  the 
'Guy's  Reports,'  by  Mr.  Wilkinson  King,  in  the  years  1842  and 

1  For  another  case  of  rupture  of  the  ossophagus  after  vomiting,  in  a  man,  aged  49, 
see  '  Lancet,'  1869,  vol.  ii,  p.  337. 


112  ON    DISEASES    OF    THE    (ESOPHAGUS. 

1843.  It  is  exceedingly  frequent  to  find  the  mucous  membrane  of 
the  oesophagus  abruptly  terminating  at  the  cardiac  extremity  of  the 
stomach,  from  the  solvent  action  of  the  gastric  juice  having  extended 
to  that  line ;  but  on  opening  the  canal  of  the  oesophagus  itself  for 
several  inches  near  its  lower  extremity,  the  upper  margins  of  the 
rugas  are  often  found  deprived  of  mucous  membrane ;  and  long  shreds 
are  observed  on  stretching  out  the  tube,  these  portions  having  escaped 
digestion.  This  solution  extends  into  the  mediastinum,  as  found  in 
cases  mentioned  in  the  communication  just  referred  to,  or  into  the 
pleura  itself,  the  contents  of  the  stomach  thus  escaping  into  the  left 
pleural  cavity,  which  is  in  closer  relation  with  the  oesophagus  than 
the  right  pleura. 

Only  two  cases  of  this  perforation  of  the  oesophagus  have  occurred 
at  Guy's  during  the  last  few  years,  one  in  a  case  of  fever,  another  of 
hydrocephalus,  so  that  it  is  a  circumstance  of  unfrequent  occurrence. 
Mr.  E.  Canton,  in  the  'Lancet'  of  1859,  gives  an  instance  of  an  infant, 
set.  2  months,  who  died  comatose,  insensibility  having  come  on  two 
hours  after  the  ingestion  of  breast  milk  and  soaked  bread.  An  oval 
opening,  three-fourths  of  an  inch  in  length,  was  found  on  the  left 
side  of  the  oesophagus,  the  rent  commencing  a  quarter  of  an  inch 
above  the  diaphragm.  Its  edges  were  thin,  flocculent,  and  irregu- 
larly fringed ;  a  second  aperture  also  was  found  separated  from  the 
other  by  a  small  strip  of  undissolved  texture.  The  causes  of  gastric 
solution  are  now  more  clearly  understood  than  formerly.  The  posi- 
tion of  the  body,  the  development  of  gases  in  the  intestines  pressing 
upon  the  contents  of  the  stomach,  the  non-contracted  state  of  the 
oesophagus  itself,  are  causes  which  lead  to  the  passage  of  the  gastric 
juice  into  the  oesophagus.  'Sometimes,  indeed,  the  pressure  thus 
produced  forces  the  contents  of  the  stomach  into  the  pharynx,  and 
we  find  them  gravitating  into  the  trachea  and  bronchi. 


113 


CHAPTER   Y. 

ORGANIC  DISEASES  OF  THE  STOMACH. 

ALTHOUGH  it  is  probable  that  every  aberration  of  function  is 
marked  by  physical  change,  still  very  many  of  the  local  alterations 
of  structure  are  of  a  character  so  transient,  and  so  completely  beyond 
the  recognition  of  the  senses,  that  \ve  are  compelled  to  separate 
them  from  others  in  which  the  structure  of  a  part  is  more  evidently 
modified. 

A  division  of  this  kind  is  especially  necessary  in  the  study  of  dis- 
eases of  the  stomach,  for  the  larger  number  are  of  the  kind  in  which 
no  structural  lesion  can  be  traced.  The  chemical,  anatomical,  and 
physiological  researches  of  late  years  have,  however,  diminished  the 
number  of  simple  functional  diseases  and  have  greatly  increased  our 
knowledge  of  those  due  to  organic  lesions. 

We  shall  have  to  treat  of  the  following  abnormal  conditions  of  the 
stomach  : 

Solution  by  the  action  of  the  gastric  juice. 

Atrophy  and  hypertrophy  of  the  mucous  and  muscular  coats. 

Dilatation  of  the  stomach. 

Inflammatory  diseases — 

Catarrhal,  diphtheritic,  and  suppurative  inflammation. 
Ulce  ration. 

Fibroid  disease  of  the  pylorus. 

Cancer. 

Post-mortem  solution. — The  secretion  poured  into  the  stomach  from 
its  numerous  follicular  glands  has  a  very  important  function  to  per- 
form in  dissolving  the  nitrogenous  portions  of  food.  This  secretion, 
the  gastric  juice,  is  a  clear,  somewhat  viscid  fluid ;  it  has  an  acid  re- 
action, from  the  presence  of  hydrochloric  or  lactic  acid,  and  it  con- 
tains an  organic  substance,  pepsin,  in  small  proportionate  quantity. 
By  the  mutual  reaction  of  these  agents  on  the  organic  animal  prin- 
ciples of  ordinary  food,  assisted  by  the  temperature  of  the  body  and 
the  churning  movements  of  the  stomach,  the  solution  of  the  protein 
compounds  and  of  the  gelatin  and  chondrin  takes  place,  and  a  fluid 
is  formed  containing  peptone  compounds,  as  they  are  called,  and 
which  is  discharged  into  the  intestine  through  the  pylor'c  valve. 
The  solvent  power  of  the  gastric  juice  is  of  a  simple  chemical  kind, 
and  it  can  be  exerted  external  to  the  living  organism  when  the 
necessary  conditions  are  carried  out;  it  would  act  also  upon  the 
structures  of  the  viscus  itself,  even  during  life,  but  is  prevented  by 
the  protective  covering  of  mucus  and  epithelium,  constantly  re- 
newed by  the  living  power  of  the  part,  and,  as  shown  by  my  colleague 
Dr.  Pavy,  by  the  circulation  of  alkaline  blood  in  the  minute  capilla- 
8 


114  ORGANIC    DISEASES    OF    THE    STOMACH. 

ries  of  the  membrane.  After  death,  however,  the  chemical  action  is 
unchecked,  and  the  walls  of  the  stomach  are  dissolved ;  sometimes, 
indeed,  with  great  rapidity,  and  in  every  instance  to  some  extent,  so 
that  pathological  researches  are  interfered  with,  and  the  appearance 
of  the  stomach  is  necessarily  modified. 

John  Hunter  drew  attention  to  post-mortem  solution  in  connection 
with  diseases  and  injuries  of  the  head,  and  T.  Wilkinson  King,  of 
Guy's,  added  definite  facts  in  reference  to  the  degrees  and  position  of 
the  solution ;  Dr.  Budd,  in  his  treatise  on  Diseases  of  the  Stomach, 
has  still  further  and  very  fully  elucidated  the  subject.  The  gelati- 
nous softening  which  has  been  described  by  Andral,  Cruveilhier, 
&c.,  as  occurring  during  life,  is  now  generally  believed  to  be  a  form 
of  this  solution,  and  in  this  opinion  I  concur,  although  some  talented 
pathologists  think  differently. 

It  must  be  always  borne  in  mind,  that  after  death  blood  gravitates 
into  the  most  depending  vessels,  that  exosmosis  takes  place,  and 
chemical  action  exerts  its  influence,  unchecked  and  unmodified  by 
vital  action. 

The  amount  of  gastric  solution  depends  in  part  on  the  quantity  of 
gastric  juice  actually  in  the  stomach  at  the  time  of  death.  Gastric 
solution  is  especially  manifest  when  sudden  death  occurs  during  the 
process  of  digestion ;  and  it  is  shown  still  more  as  a  sequence  of 
cerebral  diseases,  especially  those  of  an  inflammatory  character,  in 
young  subjects,  the  follicles  having  been  stimulated  to  pour  out 
secretion  at  irregular  times,  and  in  excessive  quantity.  Time  is  re- 
quired for  the  solution,  and  the  action  proceeds  more  rapidly  in 
summer  than  during  the  coldness  of  winter.  The  stomach  is  some- 
times found  completely  perforated,  although  food  may  not  have  been 
taken  for  several  hours  before  death. 

The  simplest  condition  of  this  change  is  thinning  and  softening  of 
the  mucous  membrane,  so  that  it  is  with  great  readiness  detached; 
if  the  bloodvessels  be  empty  the  membrane  is  pale,  and  it  has  a 
semi-gelatinous  appearance ;  generally,  however,  the  vessels  contain 
blood,  which  gravitates  into  the  most  depending  vessels ;  the  haema- 
tine  exudes  into  the  substance  of  the  stomach  itself,  and  greenish- 
brown  or  almost  black  lines  are  formed  in  the  course  of  the  vessels, 
over  the  whole  of  the  dissolved  part,  from  the  action  of  the  gastric 
juice  on  the  coloring  matter  of  the  blood.  If  the  transudation  have 
taken  place  into  the  cavity  of  the  stomach,  a  greenish-brown  fluid 
is  produced  by  a  similar  action.  This  solution  may  be  so  slight  that 
it  is  only  detected  when  we  examine  a  section  of  the  membrane  with 
the  microscope,  or  the  mucous  membrane  is  exceedingly  thinned,  or 
entirely  destroyed ;  the  submucous  and  the  muscular  coats  are  then 
dissolved,  and  at  last  the  peritoneum  is  reached.  The  serous  mem- 
brane occasionally  gives  way,  so  that  a  ragged  perforation  is  formed, 
and  the  contents  of  the  stomach  transude  into  the  peritoneal  cavity. 
The  adjoining  viscera  then  become  acted  upon,  unless  adhesions 
exist  which  have  obliterated  the  cavity,  as  we  find  in  strumous  peri- 
tonitis. 

The  extent  of  the  dissolved  part  is  marked  by  a  defined  line, 


ORGANIC    DISEASES    OF    THE    STOMACH.  115 

showing  the  level  to  which  the  solvent  fluid  has  attained.  This  is 
generally  along  the  greater  curvature;  but  sometimes,  from  the 
position  of  the  body,  we  find  that  the  solution  is  greatest  in  the 
region  of  the  lesser  curvature,  or  even  that  the  duodenum  is  espe- 
cially acted  upon ;  and  this  part  of  the  intestine  may  be  perforated 
while  the  stomach  is  intact.  Or  from  the  evolution  of  gases,  position 
of  the  body,  &c.,  the  fluid  is  pressed  into  the  oesophagus ;  the  mucous 
membrane  of  that  canal  is  dissolved,  and  sometimes  all  its  coats  per- 
forated, so  that  the  contents  of  the  stomach  are  found  in  the  pleural 
cavity. 

John  Hunter  attributed  these  effects  to  the  fact  that  chemical  action 
is  unchecked  by  the  vital  state  of  the  parts ;  but  Dr.  Bernard  and 
Dr.  Pavy1  have  demonstrated  that  the  gastric  juice  will  act  upon 
living  tissues,  as  shown  by  introducing  a  rabbit's  ear  and  the  leg  of 
a  frog  into  a  gastric  fistula,  thus  proving  the  protective  influence  of 
the  gastric  epithelium  and  mucus.  These  experiments,  however, 
are  not  conclusive,  for  the  circulation  could  not  be  carried  on  in  the 
usual  free  manner,  and  the  condition  of  the  nervous  system  is  not 
sufficiently  regarded. 

When  the  anterior  part  is  acted  upon,  Dr.  Budd2  explains  the  fact 
by  the  small  quantity  of  gastric  juice,  which  was  in  the  greater  cur- 
vature, being  neutralized  either  by  ammonia  being  evolved,  or  by  the 
exudation  of  alkaline  serum  from  the  blood,  or  from  dropsical  effu- 
sion; whilst  the  small  quantity  on  the  anterior  part  has  not  been  thus 
neutralized.  The  action  of  the  gastric  juice,  Dr.  Budd  states,  may 
be  checked  by  alcoholic  liquors,  or  by  medicines  administered  before 
death.  We  are  not  acquainted  fully  with  the  causes  of  the  greater 
gastric  solution  in  some  cases  than  in  others,  for,  whilst  agreeing  with 
the  author  just  cited,  that  it  is  occasionally  very  manifest  in  cases  of 
phthisis,  renal  disease,  typhoid  fever,  and  cancer  of  the  uterus,  or 
disease  of  organs  in  which  the  stomach  is  functionally  disturbed,  we 
shall  find  an  almost  equal  percentage  of  cases  of  solution  when  such 
causes  do  not  exist.  It  is  certainly  more  manifest  in  children  and  in 
inflammatory  disease  of  the  brain,  and  is  generally  more  marked  in 
acute  than  in  chronic  disease. 

Atrophy  of  the  Mucous  Membrane. — Wasting  of  the  mucous  mem- 
brane of  the  stomach  takes  place  in  common  with  that  of  other  organs 
and  glands,  and  the  subject  has  been  elucidated  by  Dr.  Handfield 
Jones,  whose  microscopical  investigations  have  directed  particular 
attention  to  the  subject. 

The  mucous  membrane  of  the  stomach  consists  principally  of  small 
glands  or  follicles,  which  open  into  minute  pits  on  the  surface,  and 
secrete  the  gastric  juice,  the  most  important  solvent  of  food.  Be- 
tween the  terminal  extremities  of  the  follicles  clusters  of  lymph 
cells  are  observed.  The  follicles  rest  on  a  stratum  of  connective  tissue 
of  varying  thickness,  beneath  which  is  a  layer  of  non-striated  muscu- 
lar fibre.  The  delicate  capillary  branches  of  the  bloodvessels,  derived 

1  'Guy's  Reports,'  vol.  ii,  third  series,  and  '  Phil.  Trans.' 

2  '  Budd  on  the  Stomach.' 


116  ORGANIC    DISEASES    OF    THE    STOMACH. 

from  the  coronary,  hepatic,  and  splenic  arteries,  extend  between  these 
gastric  follicles  in  nearly  a  straight  course,  and  they  form  a  beautiful 
plexus  of  vessels  around  the  minute  crypts,  and  also  beneath  the 
follicles  themselves.  These  structures  are  easily  observed  under  a 
low  magnifying  power  of  the  microscope,  and  in  a  portion  of  con- 
gested membrane  present  a  beautiful  appearance.  The  sympathetic 
nerve  filaments  are  also  seen  at  the  base  of  the  mucous  membrane, 
sometimes  upon  the  capillary  vessels,  and  at  other  times  apparently 
leaving  them,  forming  a  close  plexus  interspersed  with  numerous 
ganglia  in  the  submucous  tissue  ;  filaments  extend  both  to  the  peri- 
toneal surface  and  to  the  mucous  membrane. 

The  surface  presents  columnar  epithelium  and  mucus,  and  the 
follicles  contain  spheroidal  epithelium  and  nuclei.  As  in  every  other 
gland,  these  minute  and  simple  ones  appear  to  have  varying  degrees 
of  functional  activity,  and  undergo  degenerative  changes.  Thus  in 
many  cases  of  fatal  disease,  with  gradually  increasing  exhaustion, 
only  a  small  quantity  of  food  is  taken  for  many  days  before  death, 
whilst  in  other  instances  the  appetite  is  maintained  to  the  last ;  we 
consequently  often  observe,  that  in  the  one  case,  the  follicles  are  full 
of  secreting  cells  and  nuclei ;  whilst  in  the  other  they  are  compara- 
tively empty. 

Microscopical  investigation  has  done  much  to  increase  the  knowl- 
edge of  pathology  ;  but  with  increase  of  microscopical  power  we  must 
add  equal  caution  in  removing  all  the  causes  liable  to  mislead  us. 
The  mode  which  I  have  adopted  in  preparing  sections,  and  which 
will  generally  be  found  a  successful  one,  is  to  stretch  the  membrane 
over  or  between  the  fingers,  and  then,  by  means  of  Valentin's  knife, 
make  a  section  of  the  required  depth  and  thickness.  This  is  after- 
wards removed  by  scissors,  and  spread  out  in  water  by  needle  points. 
I  have  examined  with  great  care  a  considerable  number  of  stomachs 
from  the  post-mortem  table  of  Guy's  Hospital ;  but  it  is  not  necessary 
to  mention  the  cases  in  which  the  membrane  appeared  in  a  healthy 
condition.  In  many  of  these  examinations  I  have  observed  appear- 
ances precisely  corresponding  to  the  descriptions  and  drawings  of  Dr. 
Handfield  Jones ;  but  I  think  we  must  carefully  consider  that  many 
of  these  appearances  may  be  produced,  by  the  mode  of  making  the 
preparation,  or  by  changes  after  death.  I  refer  to  wasting  of  the 
follicles,  nuclear  deposit  around  them,  and  the  development  of  cysts. 
The  gastric  follicles  change  very  rapidly  after  death,  and  in  a  short 
space  of  time  nothing  can  be  observed  but  the  termination  of  the 
follicle  itself  upon  the  submucous  areolar  tissue,  and  above  this  an 
irregular  aggregation  of  granules  and  nuclei.  The  basement  mem- 
brane also  rapidly  becomes  dissolved,  and  this  condition  will  be  found, 
on  microscopical  examination,  before  the  ordinary  appearances  of 
gastric  solution  are  observable  in  the  stomach.  The  greater  curva- 
ture of  the  stomach  is  in  this  way  generally  too  much  changed  to 
allow  us  to  place  much  dependence  upon  its  microscopical  examina- 
tion ;  and  for  this  reason,  it  is  evident  that  we  have  to  avail  ourselves 
of  portions  of  membrane  above  the  line  of  solution.  That  from  the 
lesser  curvature,  however,  and  from  the  pyloric  region,  is  less  gene- 


ORGANIC    DISEASES    OF    THE    STOMACH.  117 

rally  dissolved  by  the  gastric  juice,  and  is  also  the  part  most  subject 
to  morbid  changes  ;  but  the  cardiac  portion  should  also  be  examined 
when  possible.  Not  only  does  the  membrane  become  dissolved,  but 
in  some  cases,  by  decomposition,  it  becomes  emphysematous,  and 
presents  minute  vesicles  and  blebs,  which  occupy  the  substance  of 
the  tissue ;  or  the  appearance  of  the  very  minute  emphysematous 
vesicles  in  the  mucous  tissue  may  resemble  the  appearance  of  well- 
defined  cysts,  surrounded  by  nuclei.  This  is  one  source  of  fallacy, 
and  another  will  be  found  in  the  fact,  that  nuclei  are  readily  sepa- 
rated from  the  follicles  in  the  preparation  of  the  section,  and  become 
diffused  between  the  structures.  The  contents  of  the  follicles  are 
easily  detached,  and,  by  the  action  of  acetic  acid,  of  cold  water,  or  by 
mere  pressure,  a  perfect  cast  of  the  follicles  will  be  often  extruded, 
and  project  from  the  surface  of  the  membrane.  A  third  fallacy, 
which  may  considerably  mislead  us,  is  the  appearance  of  the  mucous 
coat,  altered  by  the  state  of  contraction  of  the  submucous  and  mus- 
cular coats  beneath.  The  mucous  coat  will  expand  to  the  largest 
amount  of  distension  that  the  muscular  coat  allows.  When  the  mus- 
cular coat  is  contracted,  the  usual  appearance  of  rugae  is  presented ; 
but  a  further  contraction  produces  a  mamillated  appearance  of  the 
membrane.  This  may  be  sometimes  observed,  if  we  remove  a  por- 
tion of  healthy  mucous  membrane  a  short  time  after  death  and  im- 
merse it  in  cold  water  for  a  few  hours,  this  state  of  mammillatiou  is 
then  produced.  A  thickened,  chronically-inflamed  membrane  will, 
I  believe,  present  true  mammilation  of  the  stomach ;  but  in  that 
artificially  produced,  the  manner  in  which  the  fissures  extend  nearly 
to  the  submucous  cellular  tissue,  might  lead  us  to  attribute  this 
appearance  to  a  morbid  contraction  of  the  membrane  itself.  Dr. 
Hand  field  Jones  gives,  in  his  observations  on  the  stomach,  an  origi- 
nal and  interesting  account  of  the  production  of  mammillation  ;  and 
he  attributes  these  depressions  to  wasting  of  the  membrane,  the 
breaking  up  of  nuclear  masses,  and  to  the  contraction  of  the  tissue 
beneath.  This  opinion  requires  confirmation  for,  as  far  as  my  ob- 
servations have  gone,  it  would  appear  that  mammillation  is  more 
common  than  the  existence  or  evidence  of  solitary  glands  or  sepa- 
rate nuclear  deposits  in  the  membrane ;  and  that  this  appearance  of 
simple  mammillation  may  be  easily  produced  artificially  in  a  healthy 
mucous  membrane.  A  fourth  fallacy  may  arise  from  the  direction 
of  the  section.  The  surface  of  the  stomach  being  not  that  of  a  plane 
membrane,  and  its  follicles  opening  into  crypts,  an  oblique  section 
may  readily  give  the  appearance  of  fibrous  tissue  abnormally  de- 
veloped, where  such  does  not  really  exist. 

The  whole  of  the  coats  of  the  stomach  are  sometimes  exceedingly 
wasted,  but  in  fatty  degeneration  or  atrophy  of  the  mucous  mem- 
brane this  is  not  generally  the  case.  There  are  several  degrees  of 
this  wasting  or  fatty  change.  Thus,  sometimes  the  cells  of  the 
follicles,  instead  of  presenting  a  simple  nucleus,  contain  a  great 
number  of  minute  highly  refracting  particles,  and  almost  resemble 
an  inflammatory  granule  cell,  while  the  appearance  of  the  stomach 
itself  is  otherwise  in  a  perfectly  healthy  condition ;  although  these 


118  ORGANIC    DISEASES    OF    THE    STOMACH. 

cells  are  also  found  in  other  states,  as  in  extreme  congestion  with 
superficial  ulceration,  &c.,  they  appear  to  indicate  a  diminution  of 
vital  activity  rather  than  an  excess  of  it.  At  other  times,  the 
stomach  is  found  to  be  pale,  and  here  and  there  studded  with  white 
points,  somewhat  resembling  solitary  glands,  but  not  at  all  elevated 
above  the  surface.  A  horizontal  section,  in  such  a  case,  shows 
around  the  crypts,  at  the  whitened  portion,  minute  highly  refracting 
granules  and  fatty  particles ;  and  a  vertical  section  presents  a  dark 
border  on  the  surface,  consisting  of  the  same  elements ;  these  are 
also  sometimes  observed,  more  or  less  distinctly  beneath  the  follicles. 

A  more  advanced  condition  of  atrophy  shows  the  follicles  to  be 
entirely  destitute  of  secreting  cells,  and  only  containing  granules  of 
fat,  or  perhaps  wholly  destroyed,  with  irregular  patches  of  pale 
mucous  membrane.  The  mucous  membrane  of  the  stomach  also 
undergoes  lardaceous  degeneration,  in  which  the  minute  capillary 
arterioles  are  infiltrated  by  amyloid  material:  this  is  an  uncommon 
condition,  and  only  present  with  extensive  lardaceous  disease  in  other 
organs. 

Besides  these  forms  and  degrees  of  atrophy,  which  may  be  called 
secondary,  there  are  others  which  arise  from  chronic  inflammation 
of  the  membrane,  in  which  the  structure  appears  thickened,  dense, 
and  the  mere  rudiments  of  gastric  follicles  remain.  These  may  arise 
from  fibroid  degeneration  or  cancerous  disease  slowly  encroaching 
upon  the  membrane  adjoining  it,  and  thus  leading  to  atrophy  and 
degeneration. 

The  symptoms  observed  in  some  of  the  cases  in  which  this  fatty 
change  in  the  mucous  membrane  of  the  stomach  existed,  were  a 
sense  of  great  prostration  and  exhaustion,  with  complete  loss  of 
appetite.  The  tongue  was  clean,  there  was  no  pain,  neither  was 
there  thirst,  nor  vomiting,  but  an  inability  to  take  food ;  in  cases 
where  vomiting  has  sometimes  taken  place,  it  has  possibly  been  from 
other  causes.  This  form  of  atrophy  has  been  observed  in  phthisis, 
in  struma,  in  exhausting  suppuration,  and  is  often  associated  with  a 
fatty  condition  of  the  liver.1  Wasting  of  the  mucous  membrane 
may  be  the  result  of  the  action  of  corrosive  poisons. 

In  a  patient,  set.  50,  who  died  from  extensive  strumous  disease, 
the  stomach  was  found  to  be  flaccid ;  its  mucous  membrane  was 
covered  with  a  thick  layer  of  mucus,  and  it  presented,  especially  to- 
wards the  pyloric  extremity,  several  opaque  white  patches,  about  a 
quarter  of  an  inch  in  circumference.  These  parts  were  found  to 
consist  of  degenerated  mucous  follicles.  The  follicles  had  their 
usual  outline,  but  were  filled  with  minute  fat-particles,  and  were 
destitute  of  secreting  cells. 

In  a  case  of  poisoning  by  chloride  of  zinc,  much  wasting  of  the 
mucous  membrane  of  the  stomach  was  observed,  there  was  distension, 
with  gray  lines  of  discoloration,  and  at  the  greater  curvature  an  em- 
physematous  condition. 

On  the  examination  of  the  mucous  membrane,  above  the  emphyse- 

1  Handfield  Jones. 


ORGANIC  DISEASES  OF  THE  STOMACH.          119 

matous  line,  the  ends  of  gastric  follicles  were  observed,  but  they 
were  not  covered  with  the  usual  thickness  of  membrane.  At  the 
pylorus  the  mucous  membrane  regained  its  usual  thickness,  but  it 
had  a  pitted  margin,  as  at  the  circumference  of  an  ulcer ;  near  to  it 
the  membrane  appeared  thin,  and  presented  numerous  very  minute, 
transparent  vesicles,  which  projected  upon  the  surface  of  the  mem- 
brane, and  appeared  to  consist  of  a  cyst  wall,  containing  fluid  and 
nuclei.  The  cysts,  when  ruptured,  presented  a  halo  of  fluid  and 
granules  around  it.  Other  more  minute  cysts  were  found  in  the 
substance  of  the  membrane,  particularly  towards  the  greater  curva- 
ture. They  were  about  l-30th  to  l-10th  of  an  inch  in  diameter. 

At  first,  it  appeared  that  the  development  of  cysts  in  this  case 
had  taken  place  before  death ;  but  the  greater  curvature  presented 
large  blebs  of  air,  and  the  smaller  vesicles  were,  no  doubt,  of  a  similar 
character.  The  separation  of  the  elements  of  the  membrane  by  the 
development  of  gas  had  given  rise  to  this  deceptive  cystic  appearance. 
I  have  observed  a  similar  emphysematous  condition  of  the  mucous 
membrane  in  some  other  cases,  and  it  probably  arises  from  rapid 
decomposition  taking  place  in  connection  with  partial  gastric  solu- 
tion, modified,  perhaps,  by  a  diseased  condition  of  the  membrane. 

It  occasionally  happens  that  we  find  structures  resembling  solitary 
glands  of  the  intestine  in  the  mucous  membrane  of  the  stomach. 
Thus,  a  short  time  ago,  in  examining  the  stomach  of  a  child  who  had 
died  from  chorea,  I  found  the  whole  membrane  presenting  numerous 
whitish  specks,  which  consisted  of  these  structures  imbedded  in  the 
substance  of  the  membrane.  These  are  probably  identical  in  struc- 
ture with  lymphoid  tissue. 

Hypertrophy. — An  apparent  thinning  of  the  mucous  membrane  of 
the  stomach  is  consequent  on  great  dilatation  of  the  viscus;  and 
conversely  the  lining  membrane  seems  to  be  preternaturally  thick- 
ened when  the  stomach  is  contracted,  and  large  rugae  are  formed  by 
the  inversion  of  the  mucous  membrane;  and,  as  we  have  before 
remarked,  simple  contraction  of  the  submucous  tissues  causes  a  mam- 
millated  appearance,  resembling  that  produced  by  chronic  change. 
Still  there  are  instances  arising  from  chronic  irritation  and  inflam- 
mation, and  from  prolonged  congestion,  to  which  we  shall  have  to 
refer  when  speaking  of  catarrh,  in  which  the  mucous  membrane  is 
both  thickened  and  hypertrophied.  In  other  cases,  indeed,  polypoid 
masses  are  formed  by  the  mucous  membrane,  and  I  have  observed 
large  folds  of  this  kind  surrounding  the  pyloric  orifice,  without 
evincing  symptoms  of  disease  during  the  life  of  the  patient.  Rind- 
fleisch1  considers  that  the  mammillated  state  of  the  stomach  is  due 
to  the  mucous  membrane  becoming,  by  the  hypertrophy  of  its 
glandular  layer,  too  large  for  the  muscular  coat.  Polypi  became 
developed  from  this  overgrowth,  and  "in  their  interior,  besides  the 
dilated  tiibuli,  true  cysts  are  found  scattered  here  and  there ;  these 
are  filled  with  watery  fluid  or  with  mucus.  The  interlobular  con- 
nective tissue,  together  with  the  Avails  of  the  tubes  themselves,  forms 

1  Rindfleisch,  'Pathological  Histology,'  vol.  i,  p.  419.     New  Syd.  Soc. 


120  ORGANIC    DISEASES    OF    THE    STOMACH. 

septa."     Beside  these  polypoid  elevations  of  the  mucous  membrane 
pedunculated  polypi  are  occasionally  met  with. 

Mammillation  of  the  stomach  may  thus  be  due  to  varied  patholo- 
gical conditions. 

1.  It  may  be  artificially  produced  by  simple  contraction  of  the 
muscular  coat. 

2.  It  may  be  due  to  hypertrophy  of  the  glandular  structure  of  the 
mucous  membrane. 

3.  To  wasting  and  contraction  of  intertubular  tissue  (Haudfield 
Jones). 

4.  Possibly  to  cystiform  distension  of  the  follicles. 

The  more  marked  hypertrophic  changes  which  take  place  are 
those  connected  with  the  muscular  coat,  when  there  is  obstruction 
at  the  pylorus;  the  muscular  tissue  then  becomes  stronger  and 
thicker,  at  first  in  the  proximity  of  the  obstruction ;  the  hypertrophy 
gradually  extends  its  area,  reaching  two  or  three  inches,  and  even 
over  the  whole  stomach.  This  change  is  a  preservative  one,  and  it 
tends,  though  with  less  and  less  efficiency,  to  force  the  dissolved 
aliment  through  the  diseased  part;  but  at  length  the  wasting  conse- 
quent on  the  system  not  receiving  its  proper  supply  of  nutriment 
becomes  extreme,  and  the  patient  succumbs. 

Dilatation  of  the  Stomach. — The  distension  of  the  stomach  is  due 
to  a  relaxed  condition  of  the  muscular  coat.  The  stomach  in  a 
healthy  state  contracts  npon  its  contents,  and  by  its  vermicular 
action  facilitates  the  movement  and  churning  of  the  contents,  by 
which  their  thorough  mixture  with  the  gastric  juice  is  promoted, 
their  solution  accomplished,  and  the  resulting  fluid  propelled  on- 
wards through  the  pyloric  valve.  It  is  at  the  pylorus  that  the 
muscular  fibre,  especially  the  circular  coat,  has  its  fullest  develop- 
ment. When  there  is  any  obstruction  at  this  part,  particularly  if 
it  be  gradual  in  its  origin,  the  muscular  coat  becomes  proportionately 
increased,  so  that  the  chymous  fluid  may  be  pushed  through  the 
narrowed  orifice.  We  have  already  adverted  to  this  hypertrophy 
of  muscular  fibre,  but  when  the  muscle  is  unable  to  overcome  the 
hindrance,  then  the  ensuing  dilatation  becomes  the  more  prominent 
feature,  and  gradual  distension  ensues,  till  an  enormous  size  is  at- 
tained, as  we  find  in  pyloric  disease.1  The  muscular  coat  is,  more- 
over, closely  connected  with  the  nervous  filaments  of  the  pneumo- 
gastric  nerve,  and  also  with  the  vaso-motor  nerve.  When,  from 
irritation  of  the  nervous  supply,  irregular  contraction  takes  place 
we  have  spasmodic  pain  and,  it  may  be,  hour-glass  contraction ;  but, 
when  the  nervous  supply  is  weakened,  the  muscular  coat  is  less  able 
to  contract,  and  less  competent  to  execute  its  usual  movements;  and 
under  such  circumstances  sudden  great  distension  may  so  increase 
that  the  muscular  coat  is  unable  to  contract,  the  propelling  power  is 
unequal  to  the  work,  the  muscle  is  paralyzed  from  over-distension, 
as  is  that  of  the  urinary  bladder  also  when  over-stretched. 

1  Bamberger  quotes  a  case  in  which  an  inconceivable  quantity  of  fluid  (90  Ibs.) 
filled  the  stomach.  Virchow's  'Handb.  der  Spt-ciellen  Path,  und  Ther.' 


ORGANIC    DISEASES    OF    THE    STOMACH.  121 

Dilatation  arises,  therefore,  from  several  causes.  1st.  From  ob- 
struction.— The  distension  may  be  from  obstruction  at  the  pylorus, 
and  this  impediment  at  the  outlet  produces  hypertrophy  of  the  mus- 
cular coat  of  the  stomach.  "We  shall  have  to  refer  again  to  this 
condition  when  describing  organic  disease  at  the  pylorus,  whether 
fibroid  or  cancerous,  or  simple  ulceration ;  it  is  in  this  form  of  ob- 
struction that  the  peristaltic  movements  in  the  stomach,  as  pointed 
out  by  Sir  William  Gull,  are  especially  recognized.  They  are  seen 
to  pass  from  the  left  to  the  right,  and  when  the  walls  of  the  abdo- 
men are  wasted,  are  easily  observed.  A  small  quantity  of  food  or 
water  taken  by  the  patient  may  serve  to  induce  them.  Spasmodic 
contraction  at  the  pylorus  or  pressure  from  abdominal  diseases  of 
various  kinds  may  also  produce  over-distension. 

2d.  From  paralysis. — Distension  of  the  stomach  may  arise  from 
an  exhausted  state  of  the  nervous  supply  of  the  pneumogastric,  as 
mentioned  by  Traube,1  and  also  of  the  vaso-motor  nerve.  In  these 
instances  no  peristalsis  is  observed,  for  the  muscle  is  weakened. 
This  form  of  distension  is  found  in  states  of  exhaustion,  as  from 
long  fasting,  and  in  hysteria ;  great  distension  takes  place,  with  dis- 
tress, breath lessness  from  pressure  upon  the  diaphragm,  and  some- 
times severe  pain  at  the  stomach,  passing  through  to  the  spine.  It 
would  seem  that  long  continued  vomiting  may  induce  this  form  of 
nervous  exhaustion ;  and  a  similar  condition  has  been  found  in  dis- 
eases of  the  brain  and  the  spinal  cord,  in  typhus,  cholera,  and  puer- 
peral fever.  Again,  the  fulness  of  the  stomach  in  phthisis,  and  the 
flaccid  condition  in  which  it  is  often  found  in  this  disease  after  death, 
may  be  due  to  the  paralysis  or  exhaustion  of  the  pneumogastric ; 
and  in  heart  disease,  in  which  chronic  gastric  catarrh  is  induced,  the 
flatulent  distension  of  the  stomach  is  promoted  by  a  similar  state  of 
nerve  exhaustion. 

The  remarkable  case  recorded  by  Dr.  Fagge2  was  perhaps  due  to 
nervous  exhaustion,  for  there  was  perforation  of  the  duodenum  and 
an  abscess  behind  the  colon ;  local  suppuration  in  the  neighborhood 
of  the  stomach,  such  as  empyema  and  purulent  pericarditis,  may 
also  affect  the  nervous  supply,  and  thus  favor  distension. 

3d.  From  the  paralysis  of  simple  over-distension. — Distension  of  the 
stomach  may,  however,  suddenly  take  place  and  increase  to  such  an 
extent  that  the  very  distension  itself  is  the  cause  of  the  paralysis. 
Although  not  dependent  upon  any  obstruction  at  the  pylorus,  the 
result  is  the  same  in  this  case  as  in  the  first  form ;  but,  since  the 
muscle  is  paralyzed,  there  is  no  visible  peristaltic  action. 

This  distension  may  be  due  to  the  formation  of  gas  from  indiges- 
tible food,  as  mentioned  by  Dr.  Hodgkin  in  his  'Anatomy  of  the 
Mucous  and  Serous  Membranes,'  and  severe  dyspepsia  may  also  pre- 
cede it.  The  following  table  indicates  the  class  of  cases  in  which 
distension  occurs.  It  has  been  compiled  from  the  post-mortem 
records  of  Guy's  Hospital  during  the  last  ten  years,  with  the  addition 
of  several  other  cases. 

1  'Gesammelte  Beitrage,'  ii,  988. 

2  'Gny's  Hospital  Eep.,'  ser.  iii,  vol.  xviii,  p.  1. 


122 


ORGANIC    DISEASES    OF    THE    STOMACH. 


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ORGANIC    DISEASES    OF    THE    STOMACH.  123 

Attention  was  drawn  to  distension  of  the  stomach  many  years  ago 
by  Sir  William  Gull  in  a  case  under  his  care,  and  of  which  the  draw- 
ing is  in  the  Museum  at  Guy's  Hospital,  in  which  the  stomach  filled 
the  whole  abdomen,  and  this  distension  appeared  to  be  the  cause 
of  death ;  it  has  been  well  described  by  my  colleague,  Dr.  Hilton 
Fagge,  in  the  communication  previously  alluded  to. 

The  form  of  the  abdomen  is  peculiar  in  this  kind  of  distension, 
being  full  in  the  left  hypochondrium,  but  hollow  in  the  epigastric 
space,  the  curve  of  the  upper  portion  of  the  stomach  is  dragged  ob- 
liquely downwards,  and  the  pylorus  is  situated  low  down  on  the 
right  side,  or  even  near  the  pubes.  The  greater  curvature  of  the 
stomach  is  seen  to  describe  an  arc  from  the  left  hypochondrium  in 
the  direction  of  the  pubes,  following  the  curve  of  the  abdomen.  If 
the  pylorus  be  retained  in  its  usual  position  the  stomach  may  be 
acutely  bent,  as  in  one  of  the  cases  described  by  Dr.  Fagge. 

If  the  distension  be  simply  gaseous  the  peculiar  form  just  described 
is  less  marked,  the  epigastrium  is  more  uniformly  distended,  and 
the  diaphragm  is  pressed  upon.  Fluid  necessarily  gravitates,  and 
thus  the  stomach  gradually  assumes  a  lower  position. 

The  peculiar  bulging  of  the  stomach  at  the  lower  part  of  the  abdo- 
men may  lead  to  the  supposition  that  it  consists  of  a  distended  uri- 
nary bladder,  or  it  may  be  mistaken  for  ascites,  or  hydatid  tumor,1 
or  distended  colon;  and  whilst  partially  resonant  on  percussion  it 
may  produce  a  splashing  sound  from  the  presence  of  fluid  with  air. 
The  symptoms  produced  by  this  state  of  distension  are  vomiting  of 
large  quantities  of  fluid,  of  a  grumous  brown  character,  or  watery- 
acid  mucus,  or  coffee-ground  substance.  The  relief  thus  obtained  is 
often  only  partial,  and  in  those  instances  where  there  is  pyloric  ob- 
struction, the  ejected  fluids  are  often  in  a  fermenting  condition,  with 
a  frothy,  yeast-like  surface,  and  the  sarcina  ventriculi  of  Goodsir 
may  be  recognized ;  in  these  cases  also  the  peristaltic  movement  of 
the'  stomach  is  a  sign  of  value.  The  peculiar  form  of  the  stomach, 
the  hollowness  at  the  epigastrium,  and  the  splashing  sound  produced 
on  percussion,  are  significant  diagnostic  signs.  As  to  other  general 
symptoms  there  is  distress,  the  eyes  appear  sunken,  there  is  sense  of 
exhaustion,  the  pulse  is  compressible,  and  the  bowels  are  generally 
confined.  "When  the  disease  comes  on  acutely  prostration  is  rapid, 
and  in  a  short  time  the  disease  may  prove  fatal.  In  other  cases, 
however,  the  disease  may  persist  for  many  months. 

The  case  described  by" Sir  William  Gull  was  a  remarkable  one,  for 
the  distension  of  the  stomach  was  the  only  morbid  condition,  and 
was  quickly  fatal. 

In  a  patient  lately  under  my  care,  a  lady,  aet.  60,  the  disease  com- 
menced after  nervous  shock.  Stimulants  were  given  to  relieve  this 
state  and  produced  subacute  gastritis.  Violent  vomiting  came  on, 
and  with  this  some  pain  at  the  region  of  the  duodenum  or  pylorus, 
as  if  there  was  spasmodic  contraction  or  ulceration.  The  sickness 
soon  subsided,  but  the  bowels  were  confined,  and  the  patient  did  not 

'  Bamberger,  loc.  cit. 


124  ORGANIC    DISEASES    OF    THE    STOMACH. 

gain  strength.  Gradually  the  fulness  in  the  epigastric  region  passed 
into  the  umbilical,  and  then  into  the  hypogastric  region,  the  epi- 
gastric  space  becoming  deeply  hollowed.  The  distension  had  the 
form  of  a  large  stomach,  extending  nearly  to  the  pubes;  an  attack 
of  vomiting  occasionally  took  place,  but  became  less  frequent,  recur- 
ring every  three  or  four  days,  then  once  a  week,  and  afterwards  at 
intervals  of  a  fortnight  or  longer ;  no  pain  was  produced,  but  weak- 
ness and  constipation.  No  peristaltic  movement  could  be  recognized 
in  this  case. 

The  symptoms  continued  for  more  than  a  year,  and  were  greatly 
relieved  by  treatment.  The  bowels  were  acted  on  by  enemata,  by 
castor  oil,  by  magnesia,  &c. ;  internally,  remedies  were  employed  to 
check  fermentative  action,  more  especially  hyposulphite  of  soda  with 
morphia,  and  they  afforded  great  relief  for  a  time.  Steel,  n  ux  vomica, 
&c.,  were  also  used.  The  plan  recommended  by  Kussmaul  was  tried, 
namely,  washing  the  stomach  out  with  the  stomach  pump;  but  it 
distressed  the  patient,  and  as  there  was  no  pain  it  was  not  repeated. 
This  plan,  however,  in  some  cases  has  afforded  great  relief.  Friction, 
and  gentle  manipulation  of  the  stomach,  is  sometimes  beneficial,  and 
the  application  of  an  electric  current  may  induce  more  vigorous  con- 
traction of  the  muscular  fibre.1  Nutrient  injections  repeated  several 
times  during  the  day  were  beneficial  in  the  case  just  mentioned. 

Mayer2  and  Pibram  have  stated  that,  from  experiments  on  animals, 
sudden  distension  of  the  stomach  produces  slowness  of  the  pulse  and 
increase  of  arterial  tension  by  contracting  the  vessels  ;  this  statement, 
if  correct,  may  have  an  important  bearing  on  the  severity  of  the 
abdominal  symptoms,  but  it  does  not  seem  to  be  borne  out  by  the 
clinical  sj^mptoms  of  patients  suffering  from  flatulent  distension,  where 
the  pulse  is  feeble  and  compressible. 

In  the  treatment  of  these  cases,  the  plan  advocated  by  Kussmaul 
is  worthy  of  trial,  for  it  certainly  speedily  relieves  gaseous  distension, 
and  the  removal  of  fluid  from  the  stomach  enables  the  viscus  to 
contract  more  readily.  It  is  important  to  allow  the  stomach  to  rest, 
and  for  a  time  nutrient  injections  only  should  be  used.  \Vhen  food 
is  administered  it  is  well  to  avoid  those  substances  which  are  likely 
to  ferment,  such  as  saccharine  and  farinaceous  food;  milk  and  light 
soups  may  be  taken.  As  to  medicines,  opium  or  morphia  and  alka- 
lies may  be  given ;  and,  to  check  fermentation,  carbolic  acid  -or  the 
hyposulphites;  afterwards  steel,  quinine,  and  strychnia,  may  be  used 
to  strengthen  the  muscular  action.  The  local  application  of  electri- 
city is  also  beneficial. 

Hour-ylass  Contraction. — The  form  of  the  stomach  is  sometimes 
remarkably  changed  by  the'state  of  the  muscular  coat,  not  only  by 
its  uniform  contraction,  when  it  resembles  a  piece  of  intestine,  or  by 
its  distension,  forming  an  enormous  sac,  but  by  irregular  contraction, 
when  it  assumes  the  shape  of  an  hour-glass.  This  narrowing  of  the 

1  Fiirstner  has  recently  published  some  remarks  on  the  use  of  the  induced  current 
in  dilatation  of  the  stomach  ;  in  three  cases  where  the  dilatation  occurred  in  hysterical 
females  all  were  relieved.  'Berliner,  Klin.  Wochenschrift,'  March  13th,  187(5. 

*  'Centralblatt,'  13,  1873. 


ORGANIC    DISEASES    OF    THE    STOMACH.  125 

stomach  generally  takes  place  about  the  centre,  across  the  part  that 
is  the  subject  of  ulcerative  action;  in  many  instances  the  cicatrix  of 
an  ulcer  is  found  at  the  contracted  part,  but  this  is  not  always  the 
case.  In  an  instance  of  cancerous  disease  of  the  sigmoid  flexure  of 
the  colon  and  duodenum,  in  which  the  liver  also  was  involved,  there 
was  a  fibrous  band  between  the  lesser  curvature  of  the  stomach  and 
the  liver,  and  the  cicatrix  of  an  ulcer.  The  stomach  may  also  be 
drawn  down  by  an  adherent  state  of  the  omentum.  It  is  probable 
that  pain  of  a  severe  kind  is  sometimes  due  to  this  cause ;  and  when 
recognized,  narcotic  remedies,  with  careful  regulation  of  the  diet, 
are  the  only  treatment  likely  to  be  of  service. 

Lardaceous  Disease  of  the  Stomach. — The  malnutrition  which  has 
been  called  amyloid  or  lardaceous  disease  sometimes  affects  the  coats 
of  the  stomach:  the  stomach,  however,  is  less  subject  to  this  change 
than  the  intestine,  and  it  is  only  affected  in  those  instances  in  which 
other  viscera,  as  the  liver,  kidneys,  spleen,  &c.,  are  extensively  in- 
volved. The  mucous  membrane  appears  thickened,  and  when  iodine 
is  applied  a  brownish-red  discoloration  is  produced.  If  a  section  of 
the  mucous  membrane  be  made,  the  minute  capillary  arteries  are 
found  to  be  thickened,  and  the  nutrition  of  the  mucous  membrane 
is  changed.  The  diseases  in  which  lardaceous  disease  is  especially 
observed  are  cases  of  chronic  phthisis,  and  also  old  syphilis.  In  an 
instance  of  elephantiasis  Grgecorum  with  tubercular  lung,  the  viscera, 
and  amongst  them  the  stomach,  were  affected  with  lardaceous  dis- 
ease. In  conditions  of  disease  producing  general  exhaustion,  it  is 
impossible  to  recognize  this  gastric  change  by  any  especial  symp- 
toms, nor  does  it  call  for  treatment. 

Inflammation  of  the  Stomach. — The  instances  of  acute  inflammation 
of  the  stomach,  which  have  come  under  my  own  observation,  have 
arisen  from  poisons,  as  alcohol,  arsenic,  oxalic  acid,  chloride  of  zinc, 
sulphuric  and  nitric  acids;  in  these  there  are  two  symptoms  which 
demand  particular  attention — the  absence  of  pain  at  the  stomach,  in 
most  instances,  unless  perforation  have  taken  place,  and  the  marked 
prostration  of  strength,  with  depression  of  the  pulse. 

After  irritant  and  corrosive  poisons  have  been  taken,  burning 
pain  in  the  mouth  and  throat,  charring  of  the  mucous  membrane, 
vomiting,  irritability  of  the  stomach,  purging  of  blood  or  of  loose 
fecal  evacuations,  are  produced ;  and  according  to  the  strength  of 
the  fluid  arid  its  action  on  the  pharynx,  oesophagus,  and  epiglottis, 
there  is  dysphagia  or  dyspnoea.  The  vomiting  is  generally  excessive 
from  the  primary  irritation  of  the  poison,  and  the  vomited  matters 
vary  according  to  the  character  of  the  agent  and  the  extent  of  its 
chemical  action.  Subsequently,  if  the  mucous  membrane  of  the 
stomach  or  oesophagus  have  been  destroyed,  and  fibre-plastic  exuda- 
tion have  taken  place,  contraction  is  the  result,  and  narrowing  of 
the  canal  follows.  The  period  during  which  food  is  retained  is 
according  to  the  situation  of  the  occlusion  whether  in  the  oesophagus 
or  at  the  pylorus ;  in  the  former  case,  the  food  is  at  once  regurgi- 
tated ;  in  the  latter,  it  may  be  retained  for  several  hours.  If  the 
absorption  of  nutriment  be  thus  prevented,  emaciation  takes  place, 


12G  ORGANIC    DISEASES    OF    THE    STOMACH. 

the  whole  frame  becomes  wasted  to  an  extreme  degree,  and  a  fatal 
issue  follows  in  several  weeks  or  months  after  the  poison  has  been 
swallowed.  I  must  refer  my  readers  to  Dr.  Taylor's  valuable  work 
on  '  Poisons'  for  an  account  of  the  distinctive  symptoms  produced 
by  the  various  corrosive  and  irritant  poisons. 

In  a  case  of  poisoning  by  alcohol,  the  appearance  of  the  stomach 
resulted  from  the  irritant  action  of  the  poison  ;  but  the  morbid 
change  was  of  such  a  character,  that  unless  especial  attention  had 
been  drawn  to  the  part,  it  might  very  easily  have  been  overlooked. 
The  stomach  was  minutely  injected  with  arborescent  vessels,  and 
the  congestion  was  apparently  the  remains  of  an  acute  erythematous 
inflammation. 

In  another  case,  in  which  sulphuric  acid  had  been  taken,  the 
patient  survived  for  eleven  days,  the  mucous  membrane  was  left  as 
a  detached  slough.  '  No  pain  was  complained  of,  and  death  appeared 
to  result  from  syncope. 

Absence  of  pain  was  also  shown  in  a  marked  degree  in  a  case  of 
poisoning  by  chloride  of  zinc,  from  Burnett's  disinfecting  fluid. 

In  another  case,  in  which  a  woman  had  taken  some  oxalic  acid, 
the  quantity  of  which,  however,  was  not  known,  vomiting  and  pros- 
tration were  the  only  symptoms,  and  the  patient  gradually  recovered ; 
and  in  an  instance  of  a  case  of  poisoning  by  corrosive  sublimate, 
there  was  no  pain  at  the  stomach,  except  the  tenderness  resulting 
from  the  violence  of  the  vomiting,  but  only  extreme  irritability ; 
afterwards,  as  the  enteric  inflammation  increased  in  severity,  with 
tenesmus,  &c.,  pain  came  on  about  the  umbilicus,  and  generally  in 
the  abdomen,  but  especially  over  the  colon.  The  intensity  of  the 
disease  in  the  ascending  colon  and  in  the  rectum  was  very  manifest; 
and  it  is  remarkable  how  comparatively  the  small  intestine  escaped. 
Depression  of  power,  as  shown  by  a  very  compressible  pulse,  was  a 
marked  symptom  throughout ;  but  after  the  fourth  day  on  which 
salivation  was  developed  it  became  more  evident,  and  the  patient 
quickly  succumbed.  The  oesophagus  was  acutely  diseased,  and  the 
whole  intestinal  tract  more  or  less  congested.  The  suppression  of 
urine,  and  the  coarse  as  well  as  the  congested  state  of  the  kidneys, 
were  indicative  of  extreme  irritation  of  those  glands,  but  the  whole 
character  of  the  blood  seemed  to  be  changed;  it  was  fluid  in  its 
character,  the  heart  contained  only  a  loose  coagulum,  and  this  con- 
dition of  the  blood  had  probably  an  important  influence  in  deter- 
mining the  intense  congestion  and  the  pneumonic  state  of  the  lower 
lobes  of  the  lungs.  The  patient  died  on  the  sixth  day. 

The  prognosis  in  cases  of  acute  inflammation  of  the  stomach  from 
poisons  is  generally  unfavorable,  and  care  must  be  taken  lest  the 
absence  of  pain  and  the  clearness  of  the  intellect  mislead  us  as  to 
the  injury  done  to  the  stomach.  The  action  of  the  heart  is  often 
exceedingly  feeble,  the  pulse  being  perhaps  scarcely  perceptible ; 
and  this  circumstance  is  the  cause  of  the  fatal  syncope,  which  often 
unexpectedly  supervenes. 

The  treatment  in  acute  inflammation  of  the  stomach  from  poisons 
consists — 1st,  in  the  removal  of  the  poison  ;  2dly,  in  counteracting  the 


ORGANIC    DISEASES    OF    THE    STOMACH.  127 

first  effect  by  antidotes,  and  by  protecting  the  mucous  membrane  by 
means  of  oleaginous  and  demulcent  substances ;  3dly,  in  diminishing 
the  pain  by  the  use  of  opiate  and  anodyne  agents :  4thly,  in  sustain" 
ing  the  patient  under  the  effect  of  the  nervous  shock  and  extreme 
depression  by  means  of  bland  nutriment,  and  sometimes  by  nutrient 
and  stimulating  enernata  ;  5thly,  the  secondary  effects  of  contraction 
of  the  oesophagus  and  pylorus  may  be  mitigated  by  the  use  of  fluid 
food  in  a  concentrated  form,  and  several  cases  are  recorded  in  which 
the  constriction  of  the  oesophagus  was  relieved  by  bougies.  Great 
injury  may  be  done  by  the  too  active  interference  of  the  attendant ; 
depletion  and  mercurials,  as  well  as  powerful  stimulants,  generally 
aggravate  the  mischief. 

Acute  Catarrhal  Gastritis;  Inflammatory  Dyspepsia ;  Subacute  In- 
flammation.—  Catarrh  of  the  stomach  takes  place,  probably,  in  an 
acute  form,  and  is  the  cause  of  some  of  the  varieties  of  dyspepsia ; 
but  we  are  not  cognizant  of  the  conditions  observed  after  death  in- 
dicative of  this  state,  except  that  we  sometimes  observe  intense  con- 
gestion with  excess  of  mucous  secretion.  It  very  rarely  happens 
that  any  one  can  have  the  opportunities  possessed  by  Dr.  Beaumont, 
of  observing  the  appearance  of  the  gastric  mucous  membrane  during 
life ;  he  found  sometimes  an  erythematous  condition,  with  deficient 
gastric  secretion,  arising  from  irritating  food  or  stimulants.  These 
cases  of  dyspepsia  are  no  more  functional  in  their  character  than 
coryza  or  slight  conjunctivitis.  In  ordinary  catarrh,  after  exposure 
to  cold,  we  find  there  is  generally  partial,  often  complete,  loss  of- 
appetite,  and  occasionally  diarrhoea,  the  mucous  membrane  of  the 
stomach  joining  in  the  general  condition. 

In  the  dyspepsia  just  mentioned  the  symptoms  are  nausea  or 
vomiting  increased  by  food,  craving  for  cold  drinks,  injection  of  the 
tongue,  and  enlargement  of  the  papillae,  with  sometimes  an  abundant 
yellowish-white  fur,  tenderness  and  uneasiness  at  the  scrobiculus 
cordis,  pain  extending  to  the  back  between  the  shoulder-blades,  loss 
of  appetite,  languor,  headache,  and  an  incapacity  or  unwillingness 
for  mental  or  physical  exertion,  an  anxious  care-worn  countenance, 
with  a  sunken  condition  of  the  eyes.  Oftentimes  there  is  slight 
febrile  disturbance,  with  a  burning  sensation  at  the  palms  of  the 
hands  and  soles  of  the  feet ;  the  bowels  become  irritable  or  consti- 
pated ;  the  urine  is  high-colored,  and,  with  nitric  acid,  assumes  a 
deep-red  color,  or  it  deposits  litbates  abundantly.  When  vomiting 
is  severe,  bright-green  fluid  and  mucus  are  often  ejected.  This  state, 
in  not  a  few  instances,  passes  into  a  more  chronic  form  of  the  disease, 
which  is  often  called  chronic  gastritis,  a  condition  which  is  indicated 
by  soreness  at  the  scrobiculus  cordis ;  by  pain,  which  extends  to  the 
spine;  by  sallowness  of  the  complexion,  and  an  anxious,  distressed 
countenance ;  by  injection  of  the  tongue,  which  is  sometimes  like 
raw  beef,  or  has  red  patches  upon  it,  as  if  deprived  of  epithelium  ; 
by  a  compressible  pulse,  and  by  emaciation.  The  pain  at  the  stomach 
is  increased  by  food  in  every  form.  This  disease  is  often  very  ob- 
stinate, and  persists  month  after  month ;  and  although  we  have  no 
evidence  of  actual  ulceration  and  destruction  of  the  surface  of  the 


128  ORGANIC    DISEASES    OF    THE    STOMACH. 

mucous  membrane,  still  there  is  probably  chronic  inflammatory 
change.  The  gums  sometimes  become  spongy,  and  the  mouth  and 
pharynx  aphthous  and  painful ;  vomiting  also  is  occasionally  a 
troublesome  s^ymptom,  and  diarrhoea  may  be  present.  Vomiting, 
tenderness  at  the  scrobiculus  cordis,  and  the  desire  for  cold  drinks, 
are  the  prominent  symptoms  of  this  inflammation  of  the  mucous 
membrane. 

There  is  a  predisposition  to  this  form  of  disease  in  strumous  sub- 
jects;  but  we  must  distinguish  this  affection  from  a  sympathetic 
irritation  of  the  stomach,  produced  in  the  early  stage  of  disease  ot 
the  lungs  and  of  the  brain,  and  to  which  we  shall  have  subsequently 
to  refer.  And,  we  find  towards  the  close  of  phthisis,  of  cirrhosis,  of 
strumous  peritonitis,  &c.,  a  state  arises,  which  although  associated 
with  a  general  condition  of  exhaustion,  closely  simulates  what  we 
have  described  as  chronic  gastritis:  in  these  instances,  however,  the 
small  and  large  intestines  are  often  implicated,  and  we  find  a  flush 
on  one  cheek,  profuse  perspirations  at  night,  preceded  by  dry  burn- 
ing heat;  the  bowels  are  at  one  time  confined,  at  another  relaxed, 
and  the  motions  are  very  offensive  in  character.  These  symptoms 
are  often  associated  with  great  irritability  of  temper,  fretfulness,  and 
sometimes  with  delirium.  (See  Gastro-enteritis.) 

In  the  disease  to  which  my  late  colleague,  Dr.  Addison,  gave 
especial  attention  towards  the  close  of  his  life,  "  melasma  supra 
renale,"  irritability  of  the  stomach  and  great  prostration  of  strength 
are  the  two  most  prominent  symptoms;  and  so  closely  do  the  symp- 
toms resemble  those  produced  by  poisons,  and  so  frequent  are  the 
traces  of  gastric  irritation  found  after  death,  that  it  has  often  been 
questioned  how  far  these  gastric  symptoms,  with  bronzed  discolora- 
tion of  the  skin,  are  due  to  sympathetic  disturbance,  and  how  far 
to  disease  of  an  inflammatory  character.  In  instances  of  this  kind 
which  have  come  under  our  notice  superficial  ulceration  of  the  stom- 
ach has  been  observed,  in  others  arborescent  injection  of  the  capil- 
liaries,  with  ecchymosis  and  an  excess  of  tenacious  mucus. 

As  to  remedial  measures,  stimulants  aggravate  the  malady;  but 
leeches  may  sometimes  be  applied  in  severe  instances  to  the  scro- 
biculus cordis;  whilst  generally,  cool  drinks,  soda  water,  or  ice 
mitigate  the  symptoms,  and  may  be  used  with  solution  of  potash  and 
demulcents,  or  with  magnesia  and  opium.  The  carbonate  or  nitrate 
of  bismuth,  with  carbonate  of  soda  and  spirit  of  chloroform  in  almond 
emulsion,  is  of  great  service  in  these  conditions.  If  the  bowels  are 
confined,  saline  aperients  should  be  given,  as  the  carbonate  of  mag- 
nesia and  soda,  with  lemon-juice  or  citric  acid.  Mercurial  purgatives 
are  sometimes  used,  and  have  the  advantage  of  thoroughly  unload- 
ing the  bowels  and  of  diminishing  capillary  and  portal  engorgement, 
without  increasing  the  irritability  of  the  stomach;  thus,  calomel  may 
be  given  in  doses  of  three  to  five  grains,  in  combination  with  colo- 
cynth,  aloes,  rhubarb,  henbane,  &c.;  or  blue  pill  or  gray  powder 
may  be  administered  in  similar  combination ;  or,  again,  the  calomel 
may  be  decomposed  by  alkaline  carbonates,  as  in  the  preparation  of 
soda  with  mercury  in  the  Guy's  Pharmacopoeia.  It  is  well  also  to 


ORGANIC    DISEASES    OF    THE    STOMACH.  129 

follow  these  mercurial  purgatives  with  a  warm  aperient  draught,  so 
as  to  produce  a  full  and  copious  evacuation.  To  give  mercurial 
preparations,  so  as  to  affect  the  system  generally,  we  think  to  be 
positively  injurious,  and  it  is  better  when  they  can  be  altogether 
dispensed  with;  saline  aperients,  followed  by  vegetable  tonics,  and 
a  bland,  unstimulating  diet,  are  generally  sufficient.  Local  applica- 
tions to  the  pit  of  the  stomach  are  also  useful  in  lessening  the  vomit- 
ing and  the  pain,  as  mustard  or  linseed  poultices,  chloroform  liniment, 
with  belladonna  liniment,  &c.  Subsequently,  if  the  appetite  fail,  and 
the  mucons  membrane  be  relaxed,  benefit  accrues  from  the  internal 
administration  of  the  dilute  nitric  or  nitro-hydrochloric  acids,  with 
vegetable  infusions,  as  calumba,  cascarilla,  cusparia,  or  gentian. 

In  the  more  chronic  forms  the  means  best  calculated  to  afford 
relief  are  the  giving  of  nourishment  in  small  quantities,  of  a  char- 
acter which  is  easily  digestible,  and  well  masticated.  Alkalies  and 
salines  relieve  the  irritability  and  congested  state  of  the  mucous 
membrane;  for  instance,  solution  of  potash,  the  bicarbonate  of  potash 
or  soda,  calcined  or  carbonate  of  magnesia,  administered  with  almond 
emulsion,  with  camphor  mixture,  or  with  any  demulcent.  If  there 
be  neuralgic  pain,  it  is  well  to  add  a  few  drops  of  dilute  hydrocyanic 
acid,  tincture  of  henbane  or  conium,  the  solution  of  morphia  or  a 
preparation  of  opium ;  or  to  give  the  trisnitrate  of  bismuth,  with 
chloric  ether. 

In  some  cases  I  have  seen  very  great  benefit  from  the  administra- 
tion of  lemon-juice  ;  the  pain  has  subsided,  and  the  toleration  of  food 
and  ability  to  digest  it  have~  considerably  increased.  It  must  be 
borne  in  mind,  in  these  cases,  that  whilst  vegetable  food  appears  to 
be  less  easy  of  digestion,  and  often  has  to  be  prohibited,  if  months 
are  allowed  to  pass  without  its  use  the  health  fails  on  that  account 
alone,  and  increased  cachexia  is  produced;  the  administration  of 
fruit,  oranges,  grapes,  &c.,  is  advisable  ;  the  juice  of  a  lemon  may  be 
taken  daily  with  relief  to  the  pain  and  distress  at  the  scrobiculus 
cordis. 

The  application  of  leeches  or  blisters  is  often  of  service,  and  in 
some  cases  I  have  known  benefit  derived  from  the  introduction  of  a 
seton  at  the  pit  of  the  stomach. 

The  action  of  the  skin  should  be  promoted ;  and  although  sudden 
and  violent  exercise  is  injurious  and  could  not  be  borne,  still,  exercise 
in  the  open  air,  and  even  horse  exercise,  is  often  very  beneficial.  A 
change  of  air  should,  if  possible,  be  made,  especially  from  a  damp 
and  relaxing  situation  to  one  of  a  more  dry  and  bracing  character. 

Chronic  Gastritis  or  Chronic  Catarrh  of  the  stomach  and  of  the  in- 
testines, although  it  may  arise  from  inflammation  affecting  the 
gastro-intestinal  tract  in  common  with  the  pulmonary  mucous  mem- 
brane, is  more  frequently  observed  as  a  consequence  of  congestive 
disease  of  the  portal  system.  The  mucous  membrane  and  sub- 
mucous  tissue  become  congested,  often  intensely  so,  or  even  ecchy- 
mosed  ;  the  membrane  has  a  swollen,  cedematous  or  granular  appear- 
ance, and  is  covered  with  a  thick  and  tenacious  layer  of  mucus. 
This  is  sometimes  found  to  be  alkaline  in  its  reaction,  is  with  difficulty 
9 


130  ORGANIC    DISEASES    OF    THE    STOMACH. 

washed  off  by  water,  and  consists  of  mucous  corpuscles,  nuclei,  and 
epithelium. 

Thickening  of  the  mucous  and  submucous  membranes,  and  gray 
discoloration  from  the  deposition  of  pigmental  granules  from  the 
long-continued  congestion  of  the  capillaries,  are  the  result  of  chronic 
catarrh.  The  follicles  of  the  stomach  are  found  very  distinct,  and 
filled  with  nuclei  and  cells,  and  there  may  be  increase  of  the  inter- 
lobular  lymphatic  elements  or  nuclear  overgrowth  in  the  sheath  of 
the  vessels. 

The  cause  of  this  condition  appears  to  be  persistent  congestion, 
but  it  may  also  arise  from  long-continued  excesses,  and  it  has  been 
observed  especially  in  tuberculosis,  as  well  as  in  phthisis.  Dr.  Wil- 
son Fox  gives  a  total  of  14  cases  out  of  36.  Of  100  stomachs  ex- 
amined, 21  had  acute  catarrh,  19  chronic  catarrh,  and  in  17  the  two 
states  were  combined.  Other  diseases  which  appear  to  predispose 
to  it  are  fevers,  Bright's  disease,  peritonitis,  and  pneumonia.  In 
chronic  bronchitis  and  emphysema,  in  valvular  or  obstructive  dis- 
ease of  the  heart,  in  cirrhosis  of  the  liver,  and  in  other  conditions, 
the  vena  portae,  and  its  tributary  branches,  become  over-filled  with 
blood,  and  consequently  the  capillary  vessels  from  the  mucous  mem- 
branes of  the  viscera  also  become  surcharged  ;  altered  secretion,  and 
the  condition  we  have  just  described,  is  the  consequence;  thus,  the 
congestion  is  not  limited  to  the  stomach,  but  extends  through  the 
whole  of  the  tract  of  the  alimentary  canal,  in  both  the  small  and 
large  intestines. 

•  These  conditions,  then,  are  not  in  themselves  primary,  but  are  the 
result  of  cardiac,  pulmonary,  or  hepatic  disease.  Sooner  or  later,  in 
most  cases,  the  signs  indicative  of  gastric  catarrh  come  on,  pain  at 
the  scrobiculus  cordis  increased  by  food,  pain  between  the  shoulders, 
occasional  vomiting,  flatulence,  oppression  at  the  stomach,  malaise, 
constipation  ;  the  flatulent  distension  after  food  becomes  exceedingly 
distressing,  so  that  scarcely  any  can  be  taken  with  comfort,  and  solid 
food  is  almost  discarded.  In  some  cases  the  pain  takes  the  form  of 
a  severe  paroxysmal  colic,  returning  day  by  day  at  a  definite  time. 

An  attack  of  haematemesis,  or  of  bleeding  from  hemorrhoids,  may 
remove  the  congestion,  and  afford  comfort  to  the  patient,  but  the 
symptoms  are  very  quickly  reproduced.  The  dyspnoea  and  palpita- 
tion of  heart  disease,  the  cough  and  gasping  for  breath  of  chronic 
bronchitis,  engage  the  attention  of  the  patient,  and  obscure  the  less 
urgent  symptoms  of  disease  of  the  alimentary  canal ;  it  is  when  the 
former  have  been  relieved  that  attention  is  directed  to  the  abdomen. 
This  state  of  catarrh  is  often  relieved  by  the  same  means  which 
mitigate  the  original  disease.  Emptying  the  portal  system  not  only 
diminishes  the  distension  of  the  right  side  of  the  heart  and  of  the 
pulmonary  vessels,  but  also  the  congestion,  which  is  the  direct  cause 
of  the  catarrh  of  the  intestines.  Purgatives,  saline,  hydragogue,  or 
mercurial,  are  generally  used,  and  sometimes  the  more  direct  means 
of  relieving  the  vessels  by  the  application  of  leeches  to  the  anus. 
The  administration  of  mineral  acids,  with  demulcents,  expectorants, 


ORGANIC    DISEASES    OF    THE    STOMACH.  131 

or  tonics,  according  to  the  condition  of  the  patient,  affords  great 
relief;  the  preparations  of  steel  may  also  be  given  with  advantage. 

Diphtheritic  Inflammation  of  the  Stomach. — Acute  inflammation  of 
the  raucous  membranes  manifests  itself  by  alteration  in  the  secretion 
and  condition  of  all  the  parts  composing  them.  The  capillaries  and 
the  blood  within  them,  the  formation  of  epithelium  or  mucous  or  of 
other  secretions,  are  modified,  and  the  whole  vital  condition  of  the 
part  deviates  from  the  healthy  state.  "'  The  more  the  conditions  of 
nutrition  deviate  from  what  is  normal,  the  more  will  the  material 
effused  from  the  vessels  deviate  from  the  normal  type."1  This  is 
exemplified  in  ordinary  catarrh  and  bronchitis,  as  compared  with 
the  effusion  of  false  membrane  in  croup  and  laryngitis,  and  with  the 
sloughing  which  is  occasionally  seen  in  some  severe  cases  of  angina. 
In  these  diseases  the  membrane  becomes  intensely  red  from  conges- 
tion of  its  capillaries,  swollen  from  effusion  of  serum  into  its  tissue, 
hot  and  more  highly  sensitive,  and  its  secretion  is  changed.  If  the 
disease  be  slight,  the  mucus  is  altered  in  quantity  rather  than  in 
quality,  or  its  cells  are  found  to  be  exceedingly  abundant  and  imper- 
fect in  their  formation,  or  mere  nuclei  are  produced.  In  croupous 
inflammation,  the  secretion  consists  of  a  blastema,  with  greater  or 
less  tendency  to  fibrillate,  containing  granules,  nuclei,  or  variously 
formed  cells.  It  is  more  or  less  adherent  to  the  membrane  beneath, 
though  not  incorporated  with  it.  The  larynx  and  trachea  are  most 
frequently  the  subject  of  the  disease,  or  perhaps  still  more,  the 
mucous  membrane  of  the  mouth  pharynx,  and  nasal  passages. 

The  real  nature  of  the  croupous  inflammatory  membrane,  notwith- 
standing all  that  has  been  written  respecting  it,  still  remains  in  some 
obscurity.  In  common  with  other  morbid  products  it  is  thought  by 
many  to  be  of  vegetable  origin.  We  shall  only  state  that  wherever 
it  occurs  it  is  from  a  membrane  formed  by  epithelial  and  lymph  or 
pus  cells  welded  together  by  a  coagulated  fibrinous  material.  This 
opinion  is  considerably  strengthened  by  the  study  of  allied  disease  in 
the  alimentary  canal.  The  mucous  membrane  of  the  bowel  dis- 
charges casts  of  coagulated  mucus.  The  reason  of  the  coagulability 
of  the  effused  material  is  probably  not  the  same  with  all  persons ; 
in  some  it  may  be,  that  the  intensity  of  the  inflammation  leads  to 
the  effusion  of  an  ordinary  coagulable  fibrin,  in  others  that  the  char- 
acter of  the  surface  and  the  secretions  with  which  the  effusion  comes 
in  contact  may  lead  to  coagulation  which  would  not  otherwise  take 
place. 

The  term  diphtheritic  inflammation  was  applied  by  Brejonneau  to 
a  form  of  acute  inflammation  of  the  mouth  and  pharynx,  accom- 
panied with  the  effusion  of  a  grayish  false  membrane  in  small  len- 
ticular or  diffused  patches,  and  followed  by  superficial  or  deeper 
ulceration,  the  disease  extending  to  the  nasal  mucous  membrane  ; 
the  same  term  is  applied  to  similar  disease  affecting  other  organs. 

Of  late  years,  however,  the  term  diphtheritic,  as  applied  to  inflam- 
matory products,  has  come  to  have  somewhat  different  significations 

1  Paget,  '  Surgical  Path.' 


132  ORGANIC    DISEASES    OF    THE    STOMACH. 

in  English  and  German  literature.  The  croupous  inflammation  of 
German  authors,  though  a  term  of  much  wider  extension,  includes 
our  diphtheritic  inflammation ;  and,  any  sloughing  disease  of  a 
mucous  surface,  where  the  whole  thickness  of  the  membrane  sloughs, 
would  be  the  diphtheria  of  the  German  pathologists.  We  make  this 
distinction,  though  it  is  not  adhered  to  by  English  writers,  because 
there  are  two  forms  of  disease  both  in  the  throat  and  stomach  which 
correspond  to  the  two  varieties.  Both  in  the  throat  and  in  the 
stomach  we  occasionally  find  a  sloughing  form  of  disease,  and  we 
also  observe  a  membranous  inflammation. 

The  stomach  is  less  prone  to  acute  inflammatory  disease  than  either 
the  small  or  large  intestine,  and  we  rarely  have  an  opportunity  of 
observing  acute  gastritis  except  as  the  result  of  irritant  poisons. 
Croupous  or  diphtheritic  inflammation  is  still  more  rare,  and  the  fol- 
lowing case,  although  in  many  respects  imperfect,  is  of  considerable 
interest ;  the  symptoms  of  disease  of  the  stomach  were  not  clearly 
marked,  but  the  patient  was  exhausted,  and  suffering  from  advanced 
syphilitic  necrosis  of  the  bones  of  the  nose,  and  was  also  the  subject 
of  disease  of  the  kidneys. 

CASE  XXXV.  Syphilis.  Diphtheritic  Inflammation  of  the  Stomach. 
Diseased  Kidneys.  Necrosis  of  the  Bones  of  the  Nose — Ann  O — ,  aet.  47, 
was  admitted,  under  Mr.  Polland's  care,  Nov.  22,  1854,  and  died  March  30th. 
She  had  had  syphilis  many  years  previously,  for  which  she  had  taken  mercury, 
and  was  admitted  in  a  state  of  general  cachexia,  with  necrosis  of  the  bones  of 
the  nose.  In  this  condition  she  continued  till  a  short  time  before  death, 
when  she  appeared  more  exhausted,  and  puffiness  of  the  hands  and  face  came 
on.  She  appeared  to  die  from  exhaustion. 

Inspection  fourteen  hours  after  death. — The  whole  of  the  soft  parts  and 
the  bones  of  the  nose  as  well  as  of  the  palate  were  destroyed.  In  the  brain 
there  was  serous  effusion.  The  lungs  and  heart  were  healthy.  The  liver 
was  fatty  and  nodulated,  and  it  contained  small  lardaceous  masses.  The 
spleen  was  firm  and  waxy,  and  it  also  contained  lardaceous  matter ;  its  weight 
was  six  ounces.  The  kidneys  were  much  degenerated,  presenting  white  de- 
posit in  the  secreting  structure,  and  the  tubes  contained  highly  refracting 
granules  (fat). 

The  stomach  presented  a  very  remarkable  appearance  ;  it  was  of 
normal  size.  The  mucous  membrane  was  intensely  congested ;  in 
numerous  parts  were  small  patches  of  thin,  yellowish,  lymph-like 
substance,  which  were  very  adherent,  and  were  composed  of  mucous 
cells,  granules,  granule  cells,  and  some  secreting  cells.  Other  parts  of 
the  mucous  membrane  were  covered  with  tenacious  mucus.  There 
was  intense  congestion  of  the  capillaries  of  the  mucous  membrane, 
the  follicles  of  which  were  distended  with  granules  and  with  secret- 
ing cells.  A  dissolute  life,  and  the  impairment  of  general  health 
by  syphilis  and  mercury,  were  the  predisposing  causes  of  this  disease 
of  the  stomach. 

Of  croupous  inflammation  of  the  stomach,  Bamberger  states  "  that 
it  is  found  in  children  with  croupous  exudation  on  other  membranes, 
and  in  adults  it  is  secondary  to  typhus,  pyaemia,  puerperal  fever, 


ORGANIC    DISEASES    OF    THE    STOMACH.  133 

cholera,  dysentery,  or  any  acute  exanthem."     It  is  sometimes  found 
in  children,  too,  after  the  administration  of  tartrate  of  antimony.1 

In  a  case  of  diphtheria,  which  was  under  the  care  of  my  colleague, 
Dr.  Pye  Smith,  in  a  child,  aet.  4J,  the  palate,  larynx,  and  trachea 
were  affected,  and  pneumonia  was  also  produced.  The  oesophagus 
was  healthy,  but  in  the  stomach,  within  the  radius  of  two  and  a  half 
inches  from  the  cardiac  orifice,  were  numerous  small  ulcers  like 
hemorrhagic  erosions,  and  some  of  them  were  covered  with  a  pellicle. 

Dr.  Fenwick  has  described  acute  inflammatory  disease  coming  on  in 
the  stomach  after  scarlet  fever,  and  in  a  case  of  hemorrhagic  small- 
pox, which  terminated  fatally  in  Guy's  Hospital  under  the  care  of 
my  colleague,  Dr.  Pavy,  the  mischief  had  extended  into  the  stomach, 
for  not  only  the  oesophagus,  but  the  stomach  and  a  great  part  of  the 
intestine,  were  lined  with  black  pulpy  fluid,  which  evidently  con- 
sisted of  blood. 

Of  the  other  form,  which  is  perhaps  better  termed  phlegmonous 
gastritis,  the  following  case  may  be  taken  as  a  typical  instance.2  A 
patient  who  died  from  gout,  with  granular  kidneys,  hypertrophy  of 
the  heart,  and  phlegmonous  colitis,  had  also  acute  disease  of  the  stom- 
ach. The  stomach  was  thickened,  and  was  rigid  from  inflamma- 
tory infiltration ;  the  surface  of  the  mucous  membrane  gave  an  alka- 
line reaction  to  test  paper ;  the  mucous  membrane  presented  patches 
of  yellowish  color,  like  fibrin  ;  these  were  adherent,  and  on  removal 
brought  away  some  of  the  mucous  membrane.  He  had  suffered  from 
diarrhoea,  and  the  intestine  presented  a  curious  state  of  its  submucous 
tissue ;  there  were  projections  like  boils  due  to  collections  of  pus  be- 
neath the  mucous  membrane ;  the  mucous  surface  was  covered  with 
lymph ;  in  other  parts  ulcers  appeared  with  ragged  bases,  some  were 
nearly  healed ;  the  whole  membrane  was  puckered,  and  the  morbid 
process  had  apparently  gone  on  for  some  time. 

Suppuration  in  the  Coats  of  the  Stomach. — Local  suppuration  in  the 
walls  of  the  stprnach  is  of  exceedingly  rare  occurrence.  The  history 
of  the  following  case  is  imperfect  in  its  details,  but  is  sufficient  to 
show  the  general  character  and  symptoms  of  such  disease.  It  is 
probable  that  the  case  was  one  of  pyaemia. 

CASE  XXXVI.  Elizabeth  T— -,  aat.  40,  was  admitted  May  2d,  1847,  into 
Guy's  Hospital.  She  was  a  married  woman,  and  a  nurse.  For  a  fortnight 
she  had  suffered  from  pain  in  the  limbs  and  back,  and  for  a  few  days  in  the 
stomach  and  chest.  The  abdominal  tenderness  subsequently  increased.  She 
had  anorexia  and  constant  vomiting  of  a  dark-colored,  bitter  fluid,  with 
intense  thirst.  Her  death  was  preceded  by  restlessness  and  stupor. 

Inspection  twenty-four  hours  after  death. — The  body  was  tolerably  nour- 
ished. The  peritoneal  cavity  contained  yellow,  opaque,  puriform  secretion, 
of  uniform  consistence,  but  of  very  offensive  odor.  At  the  pyloric  third  of 
the  greater  curvature  of  the  stomach  was  a  firm  mass,  measuring  four  and  a 
half  by  three  and  a  half  inches.  On  opening  the  stomach,  a  small  quantity 
of  greenish  fluid  escaped.  The  mucous  membrane  was  dotted  over  its  surface 
with  points  of  ecchymosis,  and  an  irregular,  dark-brown  patch,  about  the  size 

1  Bamberger,  loc.  cit.,  p.  272. 

2  'Path.  Trans.,'  1875,  Dr.  Fagge. 


134  ORGANIC    DISEASES    OF    THE    STOMACH. 

of  a  shilling,  was  found  near  the  pylorus,  at  the  centre  of  the  thickened  mass. 
When  the  peritoneal  and  muscular  coats  were  divided,  there  was  found  to  he 
a  collection  of  pus  in  the  stibmucous  cellular  tissue.  The  pus  was  semi-fluid. 
The  intestines  were  distended  with  gas  ;  but  no  disease  could  he  found  in  the 
mucous  membrane,  except  a  small  polypus  in  the  rectum.  The  liver  \\;t.s 
dark,  congested,  and  lacerable.  The  spleen  and  kidneys  were  congested. 
The  uterus  was  full  of  menstrual  blood.  (Preparation  180285.) 

In  a  case  of  pyaemia,  under  the  care  of  my  colleague,  Dr.  Moxon, 
with  fistula  of  the  rectum,  two  or  three  abscesses,  as  large  as  ha/,el 
nuts,  were  found  in  the  stomach  between  the  muscular  and  mucous 
coats.  The  serous  and  mucous  coats  were  healthy,  and  no  trace  of 
ulceration  could  be  detected. 

In  addition  to  this  form  of  local  suppuration  a  diffuse  form  has 
also  been  found  in  very  rare  cases,  perhaps  the  best  recorded  instance 
being  that  of  my  colleague,  Dr.  Hilton  Fagge,  in  the  '  Pathological 
Society's  Transactions'  for  1875,  p.  81.  The  case,  as  there  detailed, 
is  that  a  gentleman,  aat.  51,  was  taken  with  vomiting  and  retching 
at  8  A.M.  He  had  always  a  weak  digestion,  and  for  that  reason, 
during  a  late  visit  to  Brighton,  had  taken  but  very  sparingly  of  soup, 
tea,  and  other  light  food.  The  pain  was  paroxysmal  and  very  severe, 
shooting  up  to  the  right  shoulder.  He  became  a  little  delirious,  and 
had  frequent  calls  to  evacuate  his  bowels  without  any  feculent  matter 
passing,  and  he  died  quite  suddenly  at  midnight.  Barnberger,1  in 
his  description  of  phlegmonous  gastritis  or  inflammation  of  the  sub- 
mucous  cellular  tissue  of  the  stomach,  after  describing  it  as  com- 
monly secondary  to  pyaemic  aifections,  and  noting  that  Oppolzer  had 
seen  it  twice  in  puerperal  fever,  gives  a  somewhat  similar  case  in  a 
young  healthy  soldier.  The  patient  died  after  a  few  days  of  vomit- 
ing, with  violent  pain  of  the  stomach  and  high  fever  with  delirium. 
The  stomach  was  infiltrated  through  its  whole  extent  with  pus,  which 
streamed  out  on  every  section.  He  remarks  that  a  diagnosis  in  such 
cases  is  hardly  possible,  by  reason  of  the  want  of  further  recorded 
cases.  Dr.  Moxon  says  of  it,2  "  That  though  it  is  rare,  Ackermau 
has  collected  thirty  cases,  and  that  it  is  apt  to  set  up  pysemic  ab 
scesses  in  the  liver."  This,  however,  would  hardly  apply  to  the 
diffused  form  so  much  as  to  the  localized,  for  it  would  appear  that 
the  former  is  too  rapid  in  its  course  to  have  much  time  for  the  de- 
velopment of  secondary  abscesses. 

Ulceration  of  the.  Ktomach. — There  are  several  forms  of  simple 
ulceration  observed  in  the  stomach : — 1st.  Superficial  ulceration, 
affecting  only  the  mucous  membrane,  which,  although  confined  to 
the  surface,  is  associated  with  marked  gastric  symptoms.  2dly.  Fol- 
licular  ulceration.  And  3dly.  Perforating  ulcer,  acute  and  chronic. 

Long-continued  congestion  of  the  mucous  membrane  of  the  stom- 
ach not  only  produces  the  state  which  we  have  described  as  chronic 
catarrh,  but  is  also  followed  by  superficial  ulceration,  or  as  it  is 
termed  hemorrhayic  erosion ;  but  this  destruction  of  the  mucous 
membrane  is  also  the  result  of  subacute  inflammation.  The  mern- 

1  Loc.  cit.,  266.  s  '  Path.  Anat.,'  Wilks  and  Moxon,  p.  381. 


ORGANIC    DISEASES    OF    THE    STOMACH.  135 

brane  is  generally  found  to  be  congested,  especially  at  the  rugae,  and 
the  ulcers  are  situated  at  the  lesser  curvature,  or  in  the  neighborhood 
of  the  pylorus.  The  ordinary  size  of  these  ulcers  is  about  a  quarter 
of  an  inch  in  diameter ;  they  have  irregular  and  sometimes  rounded 
edges ;  as  to  color,  they  are  minutely  injected  or  pale,  and  in  depth 
they  often  reach  to  the  submucous  cellular  tissue ;  a  single  point  of 
ulceration  may  alone  be  observed,  or  several  parts  of  the  membrane 
may  be  thus  superficially  destroyed.  It  has  even  been  suggested 
that  several  of  these  ulcers  by  uniting  may  lead  to  the  larger  per- 
forating ulcer.  The  intervening  tissue  may  either  have  a  normal 
appearance,  or  present  arborescent  and  even  general  congestion, 
whilst  the  submucous  and  muscular  coats  of  the  stomach  remain  free 
from  hypertrophic  change,  unless  chronic  irritation  has  existed.  On 
further  and  microscopical  examination,  the  ulcerative  process  is 
found  to  have  irregularly  destroyed  the  gastric  follicles  laterally ; 
and  the  surface  presents  mucus-cells,  nuclei,  and  epithelium. 

The  symptoms  of  superficial  ulceration  are  sometimes  of  an  acute 
character ;  vomiting,  pain  at  the  scrobiculus  cordis,  and  between  the 
shoulders,  tenderness  at  the  epigastrium,  pyrosis,  injection  of  the 
tongue  at  the  tip  and  edges,  loss  of  strength,  and  even  great  prostra- 
tion, are  the  symptoms  which  have  been  observed  in  this  disease ; 
but  in  superficial  ulceration  other  coincident  diseases  may  exist ;  as 
disease  of  the  supra-renal  capsule,  with  long-continued  indigestion, 
phthisis,  as  in  a  case  where  there  was  great  intemperance,  and  we 
have  also  observed  it  with  chorea.  Great  prostration  of  strength  is 
often  a  marked  symptom,  and  a  most  interesting  one,  when  it  is 
viewed  in  connection  with  the  intimate  union  of  the  stomach  with 
the  large  plexuses  and  ganglia  of  the  sympathetic  nerve.  The 
association  of  some  of  these  cases  of  superficial  ulceration  with 
pyaemia,  appears  to  show  that  a  general  diseased  condition  of  the 
blood  predisposes  to  or  excites  this  change. 

In  the  class  of  cases  associated  with  portal  congestion,  vomiting  of 
coffee-ground  substance  sometimes  takes  place  before  death,  and  fluid 
of  a  similar  kind  is  found  in  the  stomach  on  post-mortem  examina- 
tion ;  chronic  congestion  followed  by  ulceration  leads  to  effusion  of 
blood,  which  gives  rise  to  this  red-colored  vomited  fluid.  Obstruc- 
tive disease  of  the  heart  and  lungs,  and  any  condition  which  inter- 
feres with  the  free  circulation  of  blood  through  the  liver,  predisposes 
to  this  form  of  disease.  This  state  of  stomach  is  often  associated 
with  chronic  catarrh,  and  the  symptoms  before  mentioned  are  gene- 
rally present,  an  attack  of  hasmaternesis  may  afford  great  relief,  but 
the  symptoms  may  be  so  masked  by  the  primary  disease  that  this 
gastric  ulceration  is  only  recognized  on  the  post-mortem  table. 

The  following  cases^  tabulated  from  the  'Guy's  Post-mortem 
Records,'  indicate  the  frequent  association  of  hemorrhagic  erosion 
with  disease  of  the  heart  and  lungs. 

1.  Cancer  of  rectum  and  liver  ;  oedema  and  gangrene  of  lungs. 

2.  Aortic  disease  ;  dropsy  ;  pulmonary  apoplexy. 

3.  Large  white  kidney  with  severe  catarrh  of  stomach. 

4.  Ulcerative  endocarditis;  adherent  pericardium. 


136  ORGANIC    DISEASES    OF    THE    STOMACH. 

5.  Disease  of  aortic  and  mitral  valves. 

6.  Lardaceous  viscera  ;  dropsy  ;  old  syphilis. 

7.  Albuminuria  ;  hypertrophied  heart. 

8.  Dilated  heart ;  imperfect  ventricular  septum  ;  dropsy. 

9.  Subacute  aortitis  ;  retroverted  valve  and  dilatation  of  the  heart. 

10.  Dilated  heart. 

11.  Aortitis;  hypertrophy  and  dilatation  of  heart. 

12.  Bruised  side ;  polypi  in  the  right  side  of  the  heart. 

13.  Purpura  hemorrhagica. 

14.  Chronic  bronchitis. 

In  the  treatment  of  superficial  ulceration  the  application  of  leeches, 
or  of  a  small  blister  to  the  scrobiculus  cordis  affords  considerable 
relief;  nitrate  of  bismuth  with  conium,  or  with  morphia,  and  hydro- 
cyanic acid,  soothes  the  irritated  membrane,  and  diminishes  pain. 
Solution  of  potash,  the  bicarbonate  of  potash,  or  of  soda,  with  ano- 
dynes and  demulcents,  render  the  mucus  less  irritating,  and  thereby 
diminish  the  congestion  of  the  mucous  membrane.  Nitrate  or  oxide 
of  silver  in  small  doses  relieves  the  pain,  and  renders  the  stomach 
more  tolerant  of  food.  Chloric  ether  also,  with  carbonate  of  soda, 
and  mucilage  mixture  or  almond  emulsion  is  often  of  great  service. 

Ice  and  cold  water  are  exceedingly  grateful  to  the  patient,  but 
stimulants  are  not  well  borne,  although  on  account  of  the  prostra- 
tion we  ar  •  often  tempted  to  give  them  ;  if  they  be  absolutely  called 
for,  they  should  be  diluted  and  mixed  with  food,  as  wine  with  arrow- 
root or  jelly,  or  a  small  quantity  of  brandy  with  soda  water.  A 
farinaceous  diet  is  more  suited  to  these  cases  than  animal  food,  which 
taxes  in  a  greater  degree  the  energies  of  the  diseased  membrane ;  it 
is  well  to  allow  three  to  four  hours  to  intervene  between  each  meal, 
unless  the  stomach  be  very  irritable,  or  the  patient  prostrate,  when 
small  and  often  repeated  quantities  are  to  be  preferred. 

In  some  cases  of  anaemia,  and  chlorosis  with  leucorrhoea,  steel  may 
be  taken  with  advantage;  it  should  be  administered  in  the  milder 
forms,  as  the  ammonio-citrate  and  tartrate,  or  in  pills,  as  the  corn- 
pound  steel  pill  with  henbane  and  rhubarb,  and  always  after  a  meal. 

In  the  congestive  forms  of  ulceration,  purgatives  relieve  portal 
congestion,  and  thus  remove  much  distress;  but  their  action  is  fol- 
lowed by  prostration,  so  that  at  last  we  are  obliged  to  suspend  them 
altogether.  Diuretics  and  diaphoretics  also  tend  to  a  similar  result ; 
small  depletions  afford  temporary  relief,  but  are  not  called  for  unless 
the  respiration  and  the  impeded  action  of  the  heart  absolutely  re- 
quire them. 

CASE  XXX VII.  Superficial  Ulceration  of  Stomach.  Diseased  Supra- 
renal Capsules — John  J — ,  aet.  22,  was  admitted  March  20th,  and  died  on 
the  following  day.  He  was  a  stonemason  by  trade,  residing  at  Lambeth,  and 
during  the  winter  had  had  pain  in  his  stomach  and  vomiting.  The  vomited 
matters  consisted  of  watery  fluid.  On  admission  the  extremities  were  cold 
and  he  was  almost  pulseless,  he  had  not  diarrhoea  but  he  had  slight  pain  in 
the  hypogastric  region.  He  rallied  a  little  after  admission,  but  vomiting  of 
bilious  matter  came  on,  and  he  appeared  to  die  from  syncope. 

The   inspection  was  made  seventeen   hours  after  death.     The  body  was 


ORGANIC    DISEASES    OF    THE    STOMACH.  137 

tolerably  nourished,  but  the  face  was  of  a  dingy  hue,  "  Melasma  Addisonii." 
The  brain  and  its  membranes  were  normal.  At  the  apices  of  the  lungs 
were  lobules  of  iron-gray  consolidated  lung,  with  some  calcareous  deposit. 
The  right  side  of  the  heart  was  moderately  distended ;  the  left  was  firmly 
contracted.  On  carefully  examining  the  stomach,  the  cardiac  extremity  pre- 
sented post-mortem  solution,  but  towards  the  lesser  curvature  the  mucous 
membrane  was  granular,  and  in  several  parts  was  destroyed  by  small  patches 
of  ulceration.  These  were  quite  superficial  and  irregular.  In  other  parts 
above  the  line  of  solution  there  was  aborescent  injection.  On  microscopical 
examination,  mucous  and  granule  cells  were  observed.  In  the  small  intes- 
tine, Brunner's  glands  in  the  duodenum,  and  Peyer's  and  the  solitary  glands 
in  the  ileum,  were  very  distinct.  The  liver  and  spleen  were  healthy ;  the 
kidneys  coarse.  The  supra-renal  capsules  were  atrophied,  being  only  forty- 
nine  grains  in  weight,  and  each  was  adherent  to  the  surrounding  parts  by 
dense  fibrous  tissue  ;  the  left  appeared  irregular  from  contraction.  The  sec- 
tion was  pale,  and  presented  fibrous  tissue,  fat,  and  cells. 

There  were  evident  symptoms  of  disease  of  the  stomach  in  the 
pyrosis,  pain,  and  vomiting  from  which  this  man  suffered.  Discolora- 
tion of  the  skin  and  the  prostration  of  strength,  which  was  very 
remarkable,  were  typical  signs  of  a  condition  which  is  now  well 
recognized  as  Addison's  disease  of  the  supra-renal  capsules. 

The  connection  of  all  these  symptoms  may  be  accounted  for  by  the 
fact  that  the  pneumogastric  nerve  not  only  supplies  the  stomach, 
and  joins  the  large  sympathetic  ganglia  of  the  solar  plexus,  but  sends 
a  large  branch  to  join  the  sympathetic  nerve  of  the  kidney  and  supra- 
renal capsule,  and  this  nerve  is  of  considerable,  size.  The  exhaustion, 
collapse,  fluttering  pulse,  present  in  many  diseases  of  the  abdomen, 
and  sometimes  produced  by  blows  on  the  epigastrium,  as  well  as  the 
neuralgic  pain  in  the  side,  with  gastric  irritation  or  ulceration,  arise, 
no  doubt,  from  this  cause,  namely,  the  connection  of  the  sympathetic 
with  the  pneumogastric  and  spinal  nerves. 

CASE  XXXVIII.      Chorea.     Endocarditis  of  the  Mitral.      Ulceration  of 

the  Stomach Elizabeth  C — ,  aet.  18,  was  admitted  March  28th,  into  Guy's 

Hospital.  For  two  weeks  before  death  she  had  very  severe  chorea,  with  con- 
stant jactitation,  and  sleeplessness ;  gradual  exhaustion  supervened.  The 
mucous  membrane  of  the  stomach  was  softened  and  partially  dissolved  at  the 
greater  curvature.  Near  the  lesser  curvature  were  several  small  congested 
patches,  in  the  centre  of  which  the  mucous  membrane  was  destroyed.  One 
of  these  had  the  appearance  of  a  cicatrix. 

On  microscopical  examination,  the  follicles  were  found  to  be  full 
of  granules,  and  cells  containing  highly  refracting  particles,  some- 
what resembling  inflammatory  cells.  Similar  cells,  with  mucus, 
were  present  on  the  surface,  and  the  capillaries  of  the  mucous  mem- 
brane were  much  congested.  The  mucous  membrane  of  the  small 
intestine  was  similarly  congested.  The  condition  of  the  stomach 
appeared  thus  to  indicate  considerable  irritation ;  but  the  severe  ner- 
vous symptoms  completely  masked  every  other  morbid  state. 

CASE  XXXIX.      Catarrh,   and  Superficial  Ulceration   of  the   Stomach. 

Cystic  Disease  of  the  Ovary Ann  A — ,  set.  23,  was  admitted  October,  1854. 

She  was  a  married  woman,  and,  with  the  exception  of  ague  several  years 


138  ORGANIC    DISEASES    OF    THE    STOMACH. 

previously,  she  had  enjoyed  good  health.  Nine  months  before  admission, 
after  vomiting,  which  had  latterly  become  habitual,  she  experienced  pain  in  the 
side,  and  the  abdomen  became  swollen.  The  enlargement  increased  and  sub- 
sequently proved  to  be  ovarian.  After  paracentesis  the  fluid  re-collected, 
and  she  was  admitted  in  a  very  enfeebled  condition.  Vomiting  came  on,  and 
she  gradually  sank. 

Inspection  fifty-eight  hours  after  death — The  peritoneum  contained  three 
to  four  quarts  of  reddish  fluid,  and  also  a  large  cystiform  tumor  formed  by  the 
right  ovary.  The  stomach  was  large ;  its  rug*  were  reddened,  and  covered 
with  a  thick  layer  of  mucus.  The  mucous  membrane  was  thin,  and  presented, 
especially  at  the  lesser  curvature,  numerous  minute  ulcers,  which  were  found 
to  extend  to  the  submucous  cellular  tissue,  and  on  their  surface  numerous 
spherical  cells,  containing  highly  refracting  particles  were  observed.  The 
other  parts  of  the  intestine  were  much  congested.  The  liver  was  fatty. 

In  this  case  the  power  of  the  patient  was  much  reduced,  and  the 
abdominal  tumor  had  exerted  considerable  pressure  on  the  vessels. 
It  appeared,  however,  that  for  some  time  before  death,  the  mucous 
membrane  of  the  stomach  had  been  in  an  irritated,  if  not  inflamed 
condition,  as  indicated  by  the  repeated  attacks  of  vomiting,  before 
any  mechanical  pressure  was  exerted  upon  the  viscus.  The  earlier 
attacks  of  vomiting  were  perhaps  due  to  sympathy  with  the  diseased 
ovary. 

Follicular  Ulceration  of  the  Stomach. — Minute  points  of  ulceration, 
varying  in  size  from  one-sixteenth  to  one-fourth  of  an  inch  in 
diameter,  are  sometimes  found  studding  the  whole  surface  of  the 
stomach.  They  do  not  extend  deeper  than  the  mucous  membrane, 
and  are  situated,  not  only  at  the  lesser  curvature,  but  over  the 
greater  part  of  the  stomach  ;  and  they  appear  sufficiently  distinct 
from  the  more  common  superficial  ulcer  to  warrant  separate  men- 
tion. They  may  be  associated  with  a  similar  condition  throughout 
the  intestinal  tract.  Dr.  Brinton  thinks  that  there  is  no  proof  of 
their  origin  in  the  gastric  follicles,  or  in  the  lenticular  glands  if  pre- 
sent; and  suggests  the  term  punctate  ulceration  as  being  more 
correct. 

This  form  of  ulceration  has  been  observed  in  children  with  severe 
gastric  symptoms ;  but  it  has  been  generally  found  after  death  when 
no  indication  of  disease  of  the  stomach  had  previously  existed,  ex- 
cepting, perhaps,  the  vomiting  of  coffee-ground  substance.  A  draw- 
ing, in  the  Museum  of  Guy's,1  from  an  infant  under  the  care  of 
Dr.  Lever,  shows  the  mucous  membrane  of  the  stomach  intensely 
congested,  and  covered  with  minute  points  of  ulceration.  The 
microscopical  appearance  of  these  minute  ulcers  presents  irregular 
edges  extending  into  the  gastric  follicles ;  the  base  consists  of  the 
submucous  tissue,  and  on  the  surface  are  numerous  cells,  either 
altered  secreting  cells,  or  inflammatory  granule  cells.  There  is  no 
proof  that  the  disease  originates  in  the  solitary  glands,  but  rather  that 
it  is  follicular  in  its  character.  These  ulcers,  in  some  cases,  are  pro- 
bably formed  a  short  time  before  death  ;  and  are  due  in  part  to  irri- 
tating secretions,  and  to  the  depressed  state  of  the  nervous  system. 

1  Drawing  No.  286'5. 


ORGANIC    DISEASES    OF    THE    STOMACH.  139 

The  disease  is  closely  allied  to  the  gastritis  folliculosa  of  Cruveilhier, 
or  to  what  is  called  hemorrhagic  erosion  ;  but  the  latter  term  is  more 
applicable  to  some  of  the  forms  of  superficial  ulceration  with  great 
congestion. 

In  connection  with  the  subject  of  follicular  inflammation  we  may- 
refer  to  an  interesting  case  which  occurred  under  the  care  of  my 
colleague,  Dr.  F.  Taylor.  In  the  stomach  of  an  illegitimate  child 
aged  8  months,  and  who  had  died  from  syphilis,  numerous  whitish 
round  spots,  about  the  size  of  "spangles,"  were  observed.  These 
were  at  first  believed  to  be  ulcers,  but  on  careful  examination  the 
mucous  membrane  was  found  to  be  entire,  but  it  could  be  easily  re- 
moved on  the  slightest  pressure — these  spots  extended  to  the  sub- 
serous  tissue.  There  was  also  ulceration  of  the  rectum. 

In  some  fatal  cases  of  hemorrhage  from  the  stomach,  a  minute 
ulcer,  scarcely  larger  than  those  just  described,  has  been  found ;  at 
the  base  of  which  the  branch  of  an  artery  has  been  observed  con- 
taining a  small  clot.1  Sometimes  there  are  seen  numerous  minute 
specks,  each  containing  a  small  clot. 

Two  cases,of  this  kind  are  recorded  by  Dr.  Murchison  in  the  'Path. 
Soc.  Trans.,'  vol.  xxi,  p.  162.  The  ulcers  were  such  a^  might  be 
called  hemorrhagic  erosions,  and  occurred  in  spirit  drinkers,  and 
both  were  fatal  from  hemorrhage. 

CASE  XL.  Follicular  Ulceratian  of  the  Mucous  Membrane  of  the  Stomach, 
trith  Renal  Anasarca  and  Diseased  Heart — Susan  K — ,  set.  67,  was  ad- 
mitted into  Guy's  in  June,  18o4.  She  had  general  anasarca,  with  albumi- 
nous urine;  the  pulse  was  irregular;  and  there  was  dyspnoea,  with  palpitation 
of  the  heart.  A  short  time  before  death,  vomiting  of  a  dark-colored  fluid 
took  place. 

On  Inspection,  coarse  congested  kidneys  were  found,  with  a  heart  weighing 
fifteen  ounces,  dilated  and  flaccid,  and  with  some  atheromatous  deposit  on  the 
mitral  and  aortic  valves.  There  were  several  small  fibrous  tumors  beneath 
the  peritoneum  covering  the  uterus.  In  the  stomach,  above  the  line  of  gastric 
solution,  were  numerous  minute  ulcerations,  about  the  size  of  a  pin's  head, 
studding  over  the  whole  of  thew  membrane,  and  without  any  thickening  of  the 
submucous  or  muscular  tissue.  See  Preparation,  Museum,  No.  180273. 

CASE  XLI.  Follicular  Inflammation  of  the  Stomach.  Burn  on  the  Leg. 
Amputation.  Abscess  in  the  Lung  and  Spleen — George  H — ,  aet.  15,  was 
admitted  into  Guy's  Hospital  April  20th,  and  died  June  23d.  He  had 
scalded  the  arm  and  leg  with  hot  tar.  The  left  leg  was  principally  injured, 
but  was  never  disposed  to  heal,  and  the  nerves  became  exposed ;  the  leg  was 
amputated  on  account  of  his  prostrate  condition  and  the  severity  of  the  pain 
from  which  he  suffered. 

Inspection  eight  hours  after  death. — The  stump  was  sloughing,  and  the  dry 
bone  projected.  The  left  arm  was  oedematous.  There  was  pytemic  pneumonia 
and  minute  abscesses  in  the  heart  and  spleen.  The  diaphragm  on  both  sides 
was  covered  with  purulent  lymph. 

The  stomach  contained  coffee-ground  fluid.  Near  the  cardiac  extremity 
were  numerous  minute  follicular  ulcers  ;  but  the  gastric  follicles  for  the  most 
part  were  found  to  be  in  a  normal  state. 

'  Drawing  No.  180r°. 


140  ORGANIC    DISEASES    OF    THE    STOMACH. 

Perforating  Ulcer  of  the  Stomach. — The  form  of  ulceration  which 
we  have  next  to  consider  has  been  designated  emphatically  ulcer  of 
the  stomach,  by  some  also  the  chronic,  and  by  others  the  perforating 
ulcer.  Some  cases  of  the  latter  description  are  not  of  a  chronic 
character,  and  ought  perhaps  on  that  account  to  be  considered  a  pa  ft ; 
many  of  those,  however,  which  have  extended  over  considerable 
periods,  terminate  in  perforation,  so  that  we  can  scarcely  separate! 
the  one  from  the  other ;  the  term  peforating  is  however  meant  to 
imply  a  tendency  to  extend  through  the  mucous,  and  also  through 
the  muscular  and  peritoneal  coats,  although  adhesions  may  prevent 
sudden  fatal  peritonitis. 

The  perforating  ulcer  has  probably  in  all  cases  been  preceded  by 
some  of  the  conditions  previously  described.  The  ulcers  are  situated 
at  the  lesser  curvature  of  the  stomach,  sometimes  towards  the  ante- 
rior, but  more  frequently  towards  the  posterior  aspect,  and  near  the 
pylorus  ;  they  vary  in  size  from  a  quarter  of  an  inch  to  three  inches, 
or  even  more,  in  diameter,  and  are  round,  oval,  or  reniform,  the 
latter  perhaps  from  the  union  of  two  ulcers.  In  the  'Dublin  Hospital 
Gazette,'  Dr.  Law  mentions  an  instance  in  which  an  ulcer  was  six 
inches  in  length  in  its  long  axis.  Dr.  Brinton,1  in  his  investigations 
on  'Ulcer  of  the  Stomach,'  states  that  in  43  per  cent,  the  ulcer  was 
situated  at  the  posterior  surface,  in  27  at  the  lesser  curvature,  in  16 
at  the  pyloric  extremity,  in  6  on  both  the  anterior  and  posterior  sur- 
faces, often  in  opposite  positions,  in  5  on  the  anterior  surface,  in  2 
at  the  greater  curvature,  and  in  2  in  the  cardiac  pouch ;  those  on 
the  anterior  surface  being  the  most  liable  to  lead  to  perforation  and 
peritonitis. 

The  edges  of  the  chronic  ulcer  are  rounded  and  elevated ;  but  in 
those  which  are  more  emphatically  termed  the  perforating  ulcer  the 
edges  are  frequently  neither  raised  nor  injected,  but  merely  present 
a  small  punch-hole  opening,  perforating  the  peritoneal  membrane. 
The  opening  is  rather  larger  on  the  mucous  surface,  but  there  is  no 
evidence  of  inflammatory  action,  and  sometimes  no  adhesion  what- 
ever with  adjoining  viscera.  More  frequently,  however,  the  edges 
of  an  ulcer  in  the  stomach  are  considerably  thickened  by  the  infil- 
tration of  fibrous  tissue  in  the  mucous  and  submucous  coat;  the 
centre  is  therefore  depressed,  and  a  hollowed  cavity  is  produced ; 
and  in  many  of  these  cases,  also,  the  disease  extends  through  the 
muscular  and  even  through  the  peritoneal  coat.  The  opening  in  the 
mucous  membrane  is' larger  than  that  of  the  muscular,  and  the  mus- 
cular than  the  peritoneal  coat,  so  that  the  ulcer  has  a  bevelled  ap- 
pearance on  its  inner  aspect.  This  fact  has  been  adduced  in  support 
of  a  theory  as  to  the  causation  of  the  perforating  ulcer,  as  we  shall 
see  in  discussing  the  pathology  of  the  affection.  If  the  peritoneum 
ulcerate  or  slough  before  adhesions  have  formed,  a  round  opening, 
as  if  a  punch-hole  had  been  made,  is  observed  to  extend  into  the 
serous  sac,  and  leads  to  rapidly  fatal  peritonitis.  If,  however,  adhe- 
sions take  place  around  the  ulcer,  its  base  is  formed  by  the  adjoining 

1  Brinton  on  '  Diseases  of  the  Stomach.' 


ORGANIC    DISEASES    OF    THE    STOMACH.  141 

viscera,  such  as  the  pancreas,  or  the  left  lobe  of  the  liver,  or  the 
spleen.  In  these  cases  the  base  of  the  ulcer,  or  cicatrix,  is  of  a 
whitish  color,  and  consists  or  fibrinous  effusion,  and  is  smooth,  or  it 
has  a  minutely  granular  appearance ;  the  edges  become  exceedingly 
firm,  and  are  formed  of  dense  fibrinous  effusion  into  the  mucous  and 
submucous  tissues.  Glandular  mucous  membrane  is  not  re-formed 
in  these  cicatrices.  It  is  of  some  importance  in  explaining  the  fre- 
quency of  hemorrhage  to  remember,  that  the  ulcer  is  most  commonly 
found  on  the  posterior  wall  of  the  stomach,  and  therefore  that  the 
floor  of  the  ulcer  is  usually  formed  by  the  pancreas,  and  that  pan- 
creatic gland  structure  appears  to  have  very  little  granulating  power. 
The  lobules  of  the  gland  are  frequently  to  be  seen  unobscured  by 
any  new  tissue  at  the  base  of  the  ulcer.  The  perforation  into  the 
peritoneum  is  sometimes  found  at  the  edge  of  a  large  ulcer  which 
has  been  closed  by  adhesion,  but  which  has  given  way  at  the  side. 
Adhesions  also  take  place  between  the  anterior  surface  of  the  stom- 
ach and  the  abdominal  parietes,  so  also  with  the  parts  in  the  lesser 
omentum,  with  the  glands,  &c.  When  the  liver  is  invaded,  we  find 
that  the  adjoining  hepatic  tissue  contains  a  considerable  infiltration 
of  white  fibrous  tissue,  and  it  is  not  very  uncommon  for  suppuration 
to  extend  round  the  base  of  the  ulcer,  and  to  invade  some  branch  of 
the  portal  vein,  either  by  direct  ulceration  into  it  or  by  secondary 
phlebitis,  and  this  leads  to  secondary  abscess  in  the  liver.  Ulcera- 
tion occasionally  leads  to  perforation  of  the  coats  of  the  adjoining 
vessels  either  at  an  early  stage,  or  when  an  ulcer  has  existed  for 
some  time.  Hemorrhages  thus  produced  are  sometimes  rapidly  fatal, 
or  they  become  checked  for  a  time,  and  they  often  recur.  Dr.  Brinton 
describes  three  varieties  of  this  hemorrhage: — 1st.  From  the  exten- 
sion of  ulceration  into  the  minute  vessels  of  the  mucous  membrane 
and  submucous  tissue,  leading  to  a  gradual  discharge  of  blood,  which 
becomes  mixed  with  the  secretions;  2dly.  Greater  hemorrhage  from 
sudden  congestion  of  the  ulcerated  surface ;  and  3dly.  Very  profuse 
bleeding  from  a  large  artery  of  the  stomach.  The  hemorrhage  from 
the  first  two  is  never  of  any  great  severity,  and  we  believe  in  fatal 
hemorrhage  from  ulceration  an  open  vessel  can  always  be  found  by 
careful  search.  The  perforated  vessel  is  often  seen  closed  by  a 
small  clot,  or  a  drop  of  blood  may  be  pressed  from  it,  and  in  large 
ulcers  may  be  sometimes  seen  like  a  small  papillary  eminence.  This 
hemorrhage,  however,  is  not  limited  to  the  gastric  arteries,  but  takes 
place  from  the  arteries  situated  at  the  base  of  the  ulcer,  and  belong- 
ing to  adjoining  viscera ;  thus,  in  one  instance  both  the  splenic  artery 
and  the  pancreatic  were  perforated  ;  and  recently,  we  had  an  instance 
in  which  the  splenic  artery  alone  was  divided.  (Preparation  in  the 
Museum  of  Guy's  Hospital.)  Dr.  Lee,  quoting  Cruveilhier,  states 
that  ulceration  into  arteries  and  perforation  take  place  more  fre- 
quently in  secondary  ulceration  of  a  cicatrix  than  with  primary 
ulceration.  Hemorrhage,  however,  often  occurs  at  an  early  period 
of  the  disease. 

The  form  of  the  stomach  may  be  greatly  changed  either  by  adhe- 
sions external  to  the  viscus,  or  by  contraction  of  the  walls  of  the 


142  ORGANIC    DISEASES    OF    THE    STOMACH. 

ulcer.  When  the  ulcer  is  situated  in  the  centre,  the  cavity  may 
appear  almost  double,  a  form  of  hour-glass  contraction.  It  is  exceed- 
ingly rare  in  simple  ulceration,  even  when  situated  at  the  pyloric 
extremity,  for  the  whole  circumference  of  ths  part  to  be  occupied 
bv  the  ulcer  or  its  cicatrix ;  the  side  is  irregularly  puckered  rather 
than  uniformly  contracted.  In  some  cases  the  ulcer  is  so  large,  and 
the  thickening  so  great,  that  the  Avhole  stomach  becomes  involved 
in  the  inflammatory  changes,  and  is  greatly  thickened,  and  conse- 
quently very  much  contracted.  The  disease  is  then  associated  with 
more  than  the  usual  emaciation,  and  the  case  will  probably  be  mis- 
taken for  one  of  cancer  at  one  or  other  orifice;  though  in  cancerous 
disease  it  is  more  common  to  find  one  or  other  orifice  surrounded. 
In  another  instance  the  part  which,  on  opening  the  stomach,  was 
supposed  to  be  the  pylorus,  was  found  to  be  a  circular  contraction 
and  a  large  ulcer,  about  an  inch  and  a  half  from  the  pylorus,  and 
healthy  mucous  membrane  intervened;  but  this  was  not  simple  ul- 
ceration; there  was  cancerous  product  in  the  contracted  omentum  at 
the  part ;  it  was  doubtful  whether  the  cicatrix  of  an  ulcer  had  been 
followed  by  cancerous  effusion  in  its  neighborhood,  and  it  is  probable 
that  this  is  really  the  case  in  some  instances.1  The  thickening  of 
the  margins  of  the  ulcer  also  encroaches  upon  the  branches  of  the 
pneumogastric,  and  leads  to  intense  pain,  violent  vomiting,  and  death 
from  exhaustion.  This  implication  of  the  nerve  structure  may  pos- 
sibly tend  to  the  production  of  the  anasmic  state  of  so  many  of  these 
patients;  the  anaemia  being  thus  a  consequence,  and  not  a  cause  of 
ulcer.  The  second  case  related  is  of  this  character.  The  ulcer 
sometimes,  also,  extends  into  the  sac  of  the  lesser  omentum,  and 
may  cause  acute  peritonitis,  or  form  an  abscess  bounded  by  the  spleen, 
diaphragm,  pancreas,  and  liver;  or  it  communicates  with  the  colon, 
or  even  with  the  parietes ;  these  latter  cases,  however,  are  generally 
of  a  cancerous  character;2  or  the  diaphragm  itself  is  perforated,  and 
pleurisy  and  empyema  are  produced. 

A  remarkable  instance  occurred  in  Guy's,  in  1845,  under  Dr.  Bar- 
low's care,  the  full  report  of  which,  by  Dr.  Wilks,  is  found  in  the 
'Medical  Gazette'  for  May,  1845,  but  I  have  given  a  brief  abstract 
of  it.  A  secondary  cavity,  partially  filled  with  air,  had  given  rise 
to  the  symptoms  of  pneumothorax.  In  another  case  which  I  have  re- 
corded, a  sinuous  ulcerated  opening  extended  through  the  diaphragm 
into  a  sloughing  cavity  of  the  lung.  A  communication  sometimes 
takes  place  from  the  colon,  but  this  appears  generally  to  extend  from 

1  With  regard  to  cancer  occurring  after  ulcer :  it  would  appear  that  it  does  so  in  two 
ways  : — 1,  by  a  transformation  of  the  simple  sore  into  a  cancerous  one.  It  is  by  no 
means  uncommon  to  find  evidence  of  a  chronic  ulcer  and  some  part  of  it  cancerous. 
This  corresponds  to  what  is  observed  in  other  parts,  and  in  the  skin  more  especially, 
where  a  chronic  ulcer  becomes  epitheliomatous.  But  there  is  another  method,  viz., 
where,  as  in  the  text,  the  sore  still  remains  simple,  but  there  is  cancer  in  the  neighbor- 
hood. These  cases,  too,  have  their  parallel  in  other  parts,  and  we  may  mention  the 
breast,  where  chronic  eczema  and  other  states  about  the  nipple  are  occasionally  fol- 
lowed, not  by  cancer  of  the  breast,  but  by  cancer  of  the  axillary  glands.  Such  cases 
have  been  dwelt  upon  particularly  by  Sir  James  Pagct. 

*  See  Dr.  Murchison  in  '  Path.  Trans.,'  vol.  viii,  and  Dr.  W.  T.  Gairdner,  in  '  Edin. 
Med.  Journal,'  1855. 


ORGANIC    DISEASES    OF    THE    STOMACH.  143 

the  intestine  to  the  stomach,  rather  than  from  the  latter  to  the  for- 
mer; and  the  ulceration  in  these  cases  is  found  more  generally  at 
the  greater  curvature.  In  a  patient  who  died  in  1847,  there  was  an 
ulcer  opening  from  the  colon  into  the  greater  curvature,  and  two 
others  from  the  greater  curvature  into  the  sac  of  the  lesser  omentum, 
forming  a  large  fecal  abscess,  which  extended  through  into  the  lung. 
Dr.  H.  Da  vies  narrates  a  case  in  the  'Pathological  Transactions,'  of 
simple  chronic  ulcer  extending  into  the  colon.  There  had  been  dys- 
pepsia and  fecal  vomiting,  whenever  the  bowels  were  constipated. 
The  patient  gradually  sank. 


144 


ORGANIC    DISEASES    OF    THE    STOMACH, 


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ORGANIC    DISEASES    OF    THE    STOMACH. 


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ORGANIC    DISEASES    OF    THE    STOMACH.  147 

Of  these  65  cases,  37  occurred  in  males,  27  in  Females. 
Causes  of  Death. 

Males.  Females. 

Hemorrhage          .....  8  5 

Perforation  .....         12  14 

Peritonitis  (without  perforation)  1  — 

Various     ......         16  8 

Not  stated     1 

37  28 

Many  facts  of  great  interest  have  been  brought  forward  in  the 
valuable  papers  of  Dr.  Brinton.  As  to  sex,  that  ulceration  of  the 
stomach  is  twice  as  frequent  in  females  as  in  males;  the  reverse  being 
the  case  in  cancer.  In  654  cases  he  found  440  were  females,  and 
214  males;  and  that  in  one  out  of  every  five  cases  more  than  one 
ulcer  was  present;  whilst  in  one  out  of  every  seven  or  eight  cases 
perforation  took  place. 

In  the  consideration  of  the  age  of  those  who  are  the  subjects  of 
this  affection,  the  cases  of  cancer  which  have  come  under  my  own 
immediate  notice  have  been  more  advanced  in  life  than  those  who 
were  the  subjects  of  ulceration  of  the  stomach.  Dr.  Brinton  has 
collected  a  large  number  of  cases,  and  he  shows  that  the  ulcer  gene 
rally  "affects  the  periods  of  middle  and  advancing  life  with  a  fre- 
quency which  gradually  increases  up  to  the  extreme  age  allotted  to 
men."  But  the  cases  of  ulcer  in  which  perforation  causing  perito- 
nitis happens  "seem  not  only  to  select  another  period  of  life,  but  to 
exhibit  a  marked  contrast  of  age  in  the  different  sexes,  the  period  of 
life  in  which  it  is  most  liable  to  occur  being  quite  a  different  epoch 
in  the  male  and  in  the  female," — in  the  female  being  between  the 
ages  of  14  and  30,  in  the  male  from  50  to  60  ;  the  diminished  risk  of 
the  female  at  the  latter  periods  of  life  rendering  the  total  risk  in  the 
same  number  of  cases  nearly  equal. 

The  same  author  states  that  in  the  female  one-half  the  instances 
of  perforation  takes  place  between  the  ages  of  14  and  20,  whilst  in 
the  male  there  is  a  constant  proportion  in  each  decade  up  to  50, 
which  diminishes  but  little  up  to  70.  The  complete  average  age 
in  the  former,  however,  being  27  years,  in  the  latter  42.  Dr.  Lees1 
mentions  that  he  has  seen  perforation  of  the  stomach  from  ulcer 
"  in  a  girl  of  8,  and  a  boy  of  9  years  of  age." 

As  to  the  situation  of  perforating  ulcer  of  the  stomach,  Dr.  Brinton 
gives  the  following  as  the  relative  situation  in  every  100  cases,  but 
the  term  perforation  here  must  be  remembered  as  being  applicable 
especially  to  those  instances  in  which  fatal  peritonitis  follows,  not  to 
those  in  which  adhesion  renders  extravasation  impossible,  as  we  so 
often  find  in  perforation  on  the  posterior  aspect. 

1  Dr.  Lees  on  "  Diseases  of  the  Stomach  and  Indigestion." 


148 


ORGANIC    DISEASES    OF    THE    STOMACH. 


In  100  ulcers  on  the  posterior  surface  perforation  occurred  in 
pyloric  sac 
middle 

lesser  curvature 
anterior  and  poster  or  surface 
cardiac  extremity 
anterior  surface 


2 

10 
13 

18 
28 
40 
85 


Dr.  Brinton  has  collected  from  varied  sources  654  cases,  but  there 
are  several  differences  in  our  smaller  number  which  are  opposed  to 
some  of  his  deductions.  In  reference  to  sex  there  are  males  37,  and 
females  28.  The  total  as  previously  given  is  65,  but  in  one  the  age 
is  not  stated ;  it  was  a  case  of  multiple  ulcer  in  an  infant,  and  the 
disease  was  of  a  different  character,  it  has,  therefore,  been  excluded. 

Of  the  males  : — the  mean  age  was  45,  youngest  21,  oldest  66. 
"        females  "     '  40  20        "       76. 

In  the  various  decades  the  ages  were  as  follows,  bearing  in  mind  that  the  males  are 
to  the  females  as  35  to  28 — 

70—80 
No.  Per  cent. 


Males 
Females 

20—30 

No.  Per  cent. 
6         17 
8        23 

30—40 

No.  Per  epnt. 
9         26 
9         26 

40—50 

No.  Per  cent. 
4          11 
2             6 

50—60 

No.  Per  cent. 
9        26 
6        17 

60—70 

No.  Per  cent. 
7          20 
1           3 

Of  the  males   : — 10  died  from  perforation — the  average  age  being  38  years. 
"        females        7  "  "  23      " 

That  is  to  say  taking  males  and  females  together  27  per  cent,  died 
of  perforation  ;  28  per  cent,  of  the  males,  25  per  cent  of  the  females. 

On  the  whole  these  facts  corroborate  those  deducible  from  Dr. 
Brinton's  larger  numbers,  but  in  less  striking  proportions.  In  regard 
to  sex,  however,  this  is  not  so,  Dr.  Brinton  puts  the  proportion  of 
males  to  females  as  1  to  2,  and  all  who  have  written  on  the  subject 
agree  with  him.  Bamberger  gives  a  still  larger  preponderance  to 
the  women,  viz.,  91  to  22. l  In  the  numbers  we  give,  the  males  are 
in  excess,  viz.,  35  males  to  28. 

There  is,  however,  reason  for  supposing  that  these  discrepancies 
are  to  a  large  extent  explained  by  the  different  sources  whence  the 
figures  are  obtained.  Some  calculate  the  proportions  from  cases  as 
diagnosed  during  life ;  others  only  from  those  which  reach  the  post- 
mortem room.  This  is  seen  from  a  perusal  of  the  latest  contribution 
to  the  etiolgoy  of  gastric  ulcer  by  Lebert.2  Taking  the  several 
statistics  of  this  author  we  get  69  males  to  183  females  while  the 
fatal  cases  are  57  males  to  41  females.  Nor  do  we  think  this  is  alto- 
gether accidental.  It  is  sufficiently  obvious  that  in  hospital  or  pri- 
vate practice  women  suffer  more  often  than  men  from  some  of  the 
symptoms  of  gastric  ulcer ;  but  it  is  probable,  that  if  the  actual 
state  of  facts  could  be  proved  many  of  these  would  have  to  be  re- 
grouped as  cases  of  gastralgia,  subacute  gastritis,  or  gastric  catarrh. 

The  following  table  gives  the  percentage  of  deaths  in  the  several 


1  Loc.,  cit.  p.  280. 

*  '  Die  Krankheiten  des  Magens,'  by  H.  Lebert.     Tiibingen,  1878. 


ORGANIC  DISEASES  OF  THE  STOMACH. 


149 


decades  as  given  by  Lebert  on  198  post-mortems  taken  from  various 
sources,  and  that  obtained  by  the  analysis  of  our  own  cases. 


Age  in  years. 
10  to  20 


20 
90 
40 
50 


30 
40 
50 
60 
70 
80 


Guy's  Hosp. 


22 
28.5 

9.5 
24 
13 

3 


The  pathology  of  ulcer  of  the  stomach  is  still  involved  in  much 
doubt  and  obscurity.  Many  theories  have  been  suggested,  and  each 
one  has  its  supporters. 

1st.  Perforating  ulcers  are  said  to  be  of  an  inflammatory  origin ; 
the  sequel  in  fact  of  chronic  gastritis  or  the  result,  the  coalescence  of 
several  small  ulcers  to  form  a  large  one. 

2d.  They  have  been  attributed  by  Rokitansky  to  congestion,  ex- 
travasation, and  subsequent  necrosis  of  tissue. 

3d.  Yirchow  has  supported  an  ernbolic  theory. 

4th.  Some  cases  have  been  thought  to  prove  that  they  are  occa- 
sionally due,  and  perhaps  frequently  so,  to  some  deterioration  of 
nerve  influence,  or  to  some  persistent  local  nervous  irritation. 

In  considering  the  pathology  of  gastric  ulcer,  however,  it  is  im- 
portant to  distinguish  between  the  acute  and  chronic  forms.  The 
determining  cause  is  different ;  the  acute  ulcer  is  rapid  in  its  forma- 
tion, and,  therefore,  it  leads  to  perforation  before  adhesion  has  taken 
place,  and  to  peritonitis ;  it  has  a  peculiar  appearance,  and  it  occurs 
at  a  definite  period  of  life,  especially  in  the  female  sex.  The  chronic 
form  is  very  insidious,  it  creeps  on  for  years.  Perforation  into  the 
peritoneal  cavity  is  more  rare,  because  adhesions  have  formed,  and 
death  from  hemorrhage  is  more  frequent. 

It  will  be  well  to  consider  separately  the  causes  which  we  have 
enumerated.  Of  those  mentioned  the  first  can  scarcely  apply  to  the 
acute  perforating  ulcer,  for  there  are  objections  to  that  form  being 
considered  as  having  essentially  an  inflammatory  origin.  The  course 
is  too  rapid  to  indicate  an  ordinary  form  of  inflammation,  and  the 
stomach  in  such  cases  does  not  show  any  evidence  of  it  after  death. 
The  ulcer  is  sharply  defined  and  without  a  trace  of  thickening,  and 
the  surrounding  mucous  membrane  is  more  or  less  healthy.  Neither 
is  a  simple  congestive  origin  satisfactorily  substantiated.  A  local 
congestion  followed  by  infiltration  of  the  coats  of  the  stomach  by 
blood  and  subsequent  necrosis  of  the  tissues  as  a  consequence,  must 
be  due,  either  to  a  local  intensification  of  a  general  gastritis,  of  which 
there  is  no  evidence  in  the  majority  of  cases,  or  else  to  some  local 
venous  stasis  or  arterial  plugging.  This,  indeed,  is  Virchow's  hypo- 
thesis,1 and  it  satisfactorily  explains  the  occurrence  of  rapid  ulcera- 
tion.  The  experiments  of  Dr.  Pavy,2  which  have  been  latterly 
confirmed  by  Panum,  show  that  the  arrest  of  the  circulation  through 


1  '  Virchow's  Archiv,'  xxv,  p.  491. 


4  '  Proceedings  of  the  Royal  Society.' 


150  ORGANIC    DISEASES    OF    THE    STOMACH. 

any  part  of  the  stomach  leads  to  digestion  of  that  part  by  the  gastric 
juice  in  contact  with  it. 

From  the  pathological  changes  in  other  structures  we  know  that 
embolism  of  the  terminal  vessels  of  any  part  leads  to  hyperaemia,  to 
extravasation  of  blood,  and  subsequent  disintegration  of  the  damaged 
tissue.  A  venous  stasis,  would,  of  course,  tend  in  the  same  direction. 
The  shape  of  the  ulcer  has  been  strongly  dwelt  upon  as  favoring  the 
embolic  theory,  and  it  has  been  pointed  out  by  Virchow  and  others 
that  the  so-called  wedge  or  cone  shape  corresponds  with  the  infarc- 
tions of  embolic  origin.  Still  direct  proof  is  wanting  that  embolism 
or  sufficient  venous  stasis  is  present  in  any  number  of  cases  to  ac- 
count for  the  frequency  of  ulcer ;  and,  moreover,  it  is  not  easy  to 
explain  why  embolism  should  take  place  in  the  gastric  arteries  and 
not  elsewhere,  and  why  it  should  occur  so  frequently  at  a  particular 
age  and  in  the  female  sex.  An  atheromatous  state  of  the  kidneys 
has  been  suggested  as  the  cause  of  the  disturbance  of  the  circulation 
by  Miiller,1  but  the  examination  of  the  coronary  vessels  does  not 
support  this  theory.  We  are  led,  therefore,  to  look  to  the  4th  cause, 
viz.,  some  deteriorated  state  of  nervous,  supply,  or  some  prolonged 
local  nervous  irritation  as  the  true  origin  of  the  acute  perforating 
ulcer.  It  is  true  that  for  this,  again,  there  is  no  direct  proof,  not 
perhaps  so  much  as  there  may  be  for  the  embolic  theory ;  but  the 
sex,  the  age,  the  habit,  the  condition  of  the  patients  in  whom  it 
occurs,  all  point  towards  the  probability  of  a  nervous  origin,  and 
pathological  processes  in  other  organs  and  tissues,  as  the  sloughing 
of  the  cornea  in  paralysis  of  the  fifth  pair,  are  sufficient  warranty 
for  entertaining  the  idea. 

With  regard  to  the  chronic  gastric  ulcer,  its  appearance  and  the 
changes  around  it  favor  the  belief  that  it  originates  in  chronic  in- 
flammatory disease.  It  may  be  set  up  in  one  or  other  of  the  various 
ways  that  have  been  mentioned  in  connection  with  the  acute  form, 
but  we  believe  that  while  other  causes  may  conduce  towards  its 
occurrence,  and  while  gastric  solution  may  tend  to  its  further  exca- 
vation, an  inflammatory  state  is  the  best  explanation  of  the  appear- 
ance of  the  ulcer. 

The  stomach  is  more  fixed  at  the  lesser  curvature,  in  fact,  this 
part  is  almost  stationary,  for  the  stomach  in  its  general  expansion 
and  consequent  movement  turns  upon  this  part  as  a  centre,  and  it  is 
at  the  lesser  curvature  that  ulceration  generally  takes  place;  the 
nerves  also  are  more  freely  distributed  there.  The  normal  distension 
of  the  stomach  takes  place  especially  at  the  greater  curvature,  but 
when  the  stomach  is  distended  after  removal,  rupture  always  occurs 
at  the  lesser  curvature;  and  this  fixity  of  position  and  the  altered 
nervous  and  vascular  supply  which  result  from  distension  may  be 
the  determining  cause  of  the  position  of  the  gastric  ulcer. 

The  symptoms  of  chronic  ulceration  are,  at  first,  those  of  ordinary 
dyspepsia,  and  are  often  very  obscure  and  imperfectly  marked  ;  thus 
slight  uneasiness  after  food,  and  constipation,  may  be  the  only  evi- 

1  '  Wurzburg,  Verhandlung, '  vi,  p.  474. 


ORGANIC  DISEASES  OF  THE  STOMACH.          151 

deuce  of  disease;  afterwards  the  pain,  witk  tenderness' in  the  region 
of  the  stomach,  especially  at^tbe  scmbisuhis  cprdisr  a^ttraote More 
attention  from  the  patient ;  the"  pain'  is  "sometimes  slight,  at  rother 
times  intense,  and  of  a  peculia'r  gtiawrag  character ;  it  is  generally 
'increased  by  food,  and  relieved  by  the  ejection  of  it ;  vomiting  is, 
therefore,  generally  present,  and  pyrosis  or  water-brash.  Other 
symptoms  are  pain  between  the  shoulders,  more  or  less  of  abdominal 
uneasiness,  constipation,  emaciation,  and  a  peculiar  pallor  and  ca- 
chexia.  Hemorrhage  and  the  ejection  of  blood  by  vomiting,  hsema- 
temesis,  or  its  discharge  by  the  bowels,  or  black  stools,  rnelasna,  are 
present  in  most  cases  at  one  or  other  stage  of  the  disease. 

The  pain  is  not  always  of  the  same  character,  but  may  be  con- 
sidered as  a  symptom  present  in  almost  every  case;  it  may  be  almost 
constant,  but  generally  undergoes  degrees  of  exacerbation,  being 
increased  by  food ;  the  patient  often  states  that  pain  comes  on  as 
soon  as  the  aliment  reaches  the  stomach,  and  continues  as  long  as  it 
is  retained;  sometimes  it  is  so  intense  that  the  patient  is  completely 
exhausted,  as  I  have  several  times  found  when  branches  of  the  pneu- 
mogastric  nerve  have  been  involved  in  the  dense  edges  of  a  chronic 
ulcer ;  at  other  times  it  is  so  slight,  that  it  only  amounts  to  tender- 
ness on  pressure  at  the  scrobiculus  cordis.  In  a  case  recently  under 
my  care,  in  which  other  signs  of  ulcer  were  present,  the  patient 
stated  that  the  pain,  was  sometimes  relieved  by  firm  pressure  against 
the  back  of  a  chair.  Position  has,  in  not  a  few  instances,  a  marked 
effect  on  the  severity  of  pain,  and  I  have  several  times  seen  the  ob- 
servation of  Dr.  Osborne1  confirmed,  that  the  influence  of  the  posi- 
tion of  the  patient  on  the  pain  serves  as  a  guide  to  the  seat  of  the 
ulcer,  according  as  the  contents  of  the  stomach  gravitate  towards  or 
away  from  the  injured  part ;  thus  in  an  ulcer  of  the  posterior  part  of 
the  lesser  curvature  the  patient  has  been  most  easy  when  leaning 
forward  and  towards  the  left  side ;  and  yet  I  have  seen  the  pain  con- 
tinue whatever  position  has  been  assumed.  In  young  women  suffer 
ing  from  well-marked  ulceration  of  the  stomach,  with  chlorosis, 
neuralgic  pain  in  the  side  may  be  present  at  the  same  time  as  tender- 
ness and  pain  at  the  scrobiculus  cordis,  and,  in  these  cases,  we  have 
increase  of  pain  during  or  prior  to  the  menstrual  periods.  The  pain 
in  the  back  is  rarely  absent  in  chronic  ulcer  of  the  stomach ;  it  is 
generally  less  severe,  and  comes  on  later  than  the  gastric  pain,  but 
is  sometimes  complained  of  more  urgently  than  that  at  the  stomach 
itself,  the  patient  often  stating  that  "  the  pain  goes  through  to  the 
back."  In  speaking  of  the  diagnostic  value  of  pain,  Dr.  Lees  states, 
"  the  occurrence  of  pain  will  often  be  of  great  assistance  in  the  diag- 
nosis between  simple  ulcer  and  cancer ;  for  it  is  an  important  and 
curious  fact,  that  there  is  seldom  pain  in  cancer  of  the  stomach, 
unless  great  obstruction  of  the  pyloric  orifice  prevents  the  passage 
of  food  out  of  this  viscus."  And  again  : — "  The  mere  fact  of  severe 
pain  constantly  occurring  after  food,  should  lead  you  to  diagnose 
simple  ulcer  of  the  stomach  rather  than  cancer.  The  pain,  moreover, 

1  '  Dublin  Journal  of  Medical  Science,  1st  ser.,  vol.  xxiv,  p.  301. 


152  ORGANIC    DISEASES    OF    THE    STOMACH. 

in  simple  ulcer,  is  often  of  a  gnawing  character,  causing  a  sense  of 
siskenihg'ti&p^spipn^  jt  is  variable  and  remittent,  sometimes  being 
very  severe  and  then  ceasing  for  days  or  even  weeks ;  but,  in  ma- 
lignant disease,  the  pain,  tliou^li  imt  often  severe  or  lancinating,  yet 
is  almost  always  constant  after  it  has  once  commenced."  Although 
all  observers  will  bear  testimony  to  the  general  variability  and 
the  gnawing  character  of  the  pain  in  ulcer  of  the  stomach,  still,  in 
some  instances,  as  when  branches  of  the  pneurnogastric  nerve  have 
been  involved  in  the  edges  of  the  ulcer,  or  laid  bare  on  its  floor,  the 
pain  is  terribly  constant.  Again,  in  cancer  of  the  pylorus,  as  in  a 
case  to  be  presently  mentioned,  there  was  no  pain  acknowledged  on 
repeated  questioning  of  the  patient  as  to  present  symptoms  or  pre- 
vious history ;  and  in  other  instances  of  cancer,  when  suffering  is 
very  severe,  the  relief  from  pain  is  often  very  great  on  the  avoidance 
of  solid  and  indigestible  food,  and  during  the  use  of  anodyne  reme- 
dies. The  dragging  pain  in  the  epigastric  region,  produced  by  adhe- 
rent omental  hernia,  and  the  pain  often  present  at  the  scrobiculus 
cordis  in  chronic  disease  of  the  lungs  and  heart,  must  be  remembered 
as  liable  to  simulate  gastric  ulcer,  and  to  obscure  the  diagnosis. 

The  period  at  which  vomiting  takes  place  in  ulceration  of  the  stom- 
ach is  equally  varied ;  sometimes  the  food  is  at  once  rejected,  in 
other  instances  it  is  retained  for  many  hours  or  days.  In  the  case 
previously  alluded  to,  in  which  the  thickened  edge  of  the  ulcer  con- 
tained a  large  branch  of  the  pneumogastric  nerve,  the  stomach  almost 
instantaneously  rejected  food,  and  the  patient  died  exhausted,  but 
if  the  nerve  be  divided  by  ulceration  or  by  sloughing  the  vomiting 
may  entirely  cease.  Fermentation  and  the  development  of  the  sar- 
cina  ventriculi  of  Goodsir1  take  place  in  some  cases  of  chronic  ulcer, 
as  well  as  in  cancer  and  diseased  pylorus.  The  sarcina  can  scarcely 
be  considered  as  a  proof  of  obstruction,  for  its  development  occurs 
without  any  impediment. 

Vomiting,  however,  as  a  sign  of  gastric  ulcer,  must  be  regarded 
with  great  care,  since  in  so  many  instances  it  is  purely  synpathetic 
in  its  origin.  Pyrosis  also  is  often  present  in  disease  of  a  less  serious 
character,  and  is  among  the  signs  of  functional  disturbance. 

Chronic  disease  of  the  abdominal  viscera  is  often  marked  by  an 
anxious  and  dejected  countenance,  with  emaciation;  in  gastric  ulcer 
this  appearance  is  present,  and  is  associated  with  pallor,  arising  from 
the  impairment  of  general  nutrition. 

In  cancerous  disease,  a  careworn  expression  is  found,  with  cachectic 
sallowness ;  and,  in  the  anemia  of  chlorosis  and  amenorrhoea,  there 
is,  in  extreme  cases,  a  waxen  appearance,  which  is  very  peculiar ;  so 
also  in  the  anasmia  after  considerable  loss  of  blood.  Again,  in  many 
instances  of  struma  and  of  glandular  disease,  pallor  is  present;  but 
in  ulcer  of  the  stomach  the  anxious  countenance  of  abdominal  disease, 
conjoined  with  emaciation  and  pallor  of  imperfect  nutrition,  afforded 
a  very  characteristic  morbid  expression,  and  as  a  symptom  is  rarely 
absent. 

1  Merismopodia  ventriculi  (Robin). 


ORGANIC    DISEASES    OF    THE    STOMACH.  153 

As  we  have  before  said,  hemorrhage  takes  place  in  most  cases  of 
gastric  ulcer  ;  vomiting  of  several  pints  or  even  quarts  of  blood  may 
be  amongst  the  earliest  symptoms  of  disease  ;  in  other  instances  the 
bleeding  is  slight,  or  entirely  absent.  It  proved  fatal  in  sixteen  cases 
of  those  which  we  have  tabulated,  or  one  in  every  four  cases.  The 
first  hemorrhage  from  the  stomach  is  occasionally  fatal ;  in  ordinary 
cases  the  discharge  of  blood  is  preceded  by  a  sense  of  weight  and 
coldness,  followed  by  faintuess  or  actual  syncope,  and  then  rejection 
of  dark -colored  blood  takes  place.  The  action  of  the  gastric  juice 
confers  this  deepened  color ;  but  if  the  effusion  be  very  rapid,  the 
color  is  more  bright ;  a  portion  of  blood  passes  onwards  into  the 
duodenum  and  intestines,  and  if  life  is  prolonged,  so  that  it  mav  be 
discharged  per  rectum,  a  black,  tarry  evacuation  is  the  result.  Some- 
times, however,  the  whole  of  the  blood  is  thus  discharged,  and  there 
is  melaena  without  heematemesis ;  but  these  symptoms  are  generally 
combined.  Instances  have  been  recorded  where  sudden  hemorrhage 
into  the  stomach  was  followed  by  fatal  syncope,  without  the  discharge 
of  blood  either  by  vomiting  or  purging ;  more  frequently  the  hemor- 
rhage is  oftentimes  repeated.  Some  of  the  most  severe  cases  of 
hemorrhage  are  those  in  which  the  dense  fibroid  tissue  of  a  chronic 
ulcer  prevents  the  retraction  of  a  perforated  vessel. 

Unless  hemorrhage,  however,  take  place,  we  cannot  with  any 
certainty  diagnose  ulceration  of  the  stomach ;  cachexia,  emaciation, 
pallor,  pain,  and  vomiting,  all  arise  without  ulceration,  in  cases  of 
irastrodynia  and  irritability  of  the  stomach,  sympathetic  or  otherwise. 
But  hemorrhage  is  not  in  itself  pathognomonic  of  ulceration ;  it  often 
arises  from  overdistended  capillaries  in  a  gorged  state  of  the  portal 
circulation,  and  in  cancerous  disease  ;  and  although  less  frequent  in 
cancer  than  in  simple  ulceration,  it  does  occasionally  arise.  Disease 
of  the  oesophagus  and  aneurism  sometimes  produce  the  same  symp- 
tom. 

The  form  of  ulceration,  however,  which  leads  to  the  most  disas- 
trous termination,  is  that  which  tends  to  fatal  perforation  into  the 
peritoneal  cavity.  These  instances  often  occur  in  young  women  af- 
fected with  chlorosis  and  amenorrhoea,  or  with  painful  menstruation; 
the  previous  gastric  symptoms  are  very  slight,  or  altogether  unno- 
ticed, although  there  is  generally  impaired  health,  with  leucorrhcea 
or  chlorosis,  neuralgic  pain  in  the  side,  and  symptoms  of  hysteria. 
The  onset  of  the  fatal  attack  is  unexpected,  and  is  generally  after 
slight  muscular  exertion,  or  after  a  full  meal ;  intense  pain  comes  on, 
followed  by  rapid  prostration  and  collapse.  The  skin  becomes  cold 
and  clammy ;  the  pulse  fails  ;  the  pain  in  the  abdomen  becomes  gen- 
eral; tympanitis  follows,  and  occasionally  vomiting  supervenes; 
death  ensues  in  from  five  to  twenty-four  hours,  although  life  is  some- 
times prolonged  for  several  days ;  but,  in  rare  cases,  the  patient  re- 
covers. The  difference  in  the  sexes  with  regard  to  the  age  at  which 
perforation  is  liable  to  occur  is  seen  in  the  table.  The  average  age 
of  males  dying  from  perforation  is  thirty-eight,  that  of  females  only 
twenty-three. 

Abercrombie  distinguishes  three    modes  of  fatal  termination  of 


154  ORGANIC    DISEASES    OF    THE    STOMACH. 

ulcer  of  the  stomach.  1,  Gradual  exhaustion  ;  2,  hemorrhage;  and  3 
perforation  into  the  peritoneal  cavity ;  others  may  be  mentioned,  as 
the  extension  of  inflammation  to  adjoining  viscera,  as  in  the  case 
related  in  which  mischief  passed  through  the  diaphragm  into  the 
lung,  and  acute  pleurisy  was  set  up ;  secondary  suppuration  in  the 
branches  of  the  portal  vein  and  pyaemia  ;  and  the  occurrence  of  pneu- 
monia or  bronchitis  from  nervous  exhaustion.  The  disease,  however, 
sometimes  remains  in  a  passive  condition,  and  the  patient  dies  of 
some  other  complaint.  It  is  not  very  rare  to  find  cicatrices  in  the 
stomach ;  and  in  those  cases  where  there  has  been  extensive  destruc- 
tion of  surface,  and  of  the  muscular  and  peritoneal  tissue,  the  ad- 
joining viscera  are  found  covered  with  a  smooth  fibrous  tissue. 

The  duration  of  life  after  the  development  of  symptoms  of  ulcer 
of  the  stomach,  as  compared  with  cancer  is  generally  very  different. 
Setting  aside  those  cases  in  which  perforation  into  the  peritoneal  sac 
takes  place,  the  ulcer  is  more  curable  aud  extends  over  a  longer 
period ;  it  may  be  several  years,  and  some  have  mentioned  cases  con- 
tinuing for  even  twenty,  and  in  one  under  my  own  observation  the 
symptoms  were  said  to  extend  over  forty  years.  I  have  several 
times  observed  patients,  men  of  middle  life,  suffering  from  severe  gas- 
tric symptoms,  with  sallow  complexion,  pain  at  the  scrobiculus  cordis, 
vomiting  of  food,  occasional  hsernatemesis,  loss  of  flesh,  &c.,  who  have 
lost  their  symptoms  under  treatment  and  care,  have  regained  flesh 
and  comfortable  health,  and  had  no  return  of  symptoms  for  several 
years.  In  cancer,  after  the  well-marked  symptoms  have  occurred, 
we  rarely  find  that  a  year  passes,  and  frequently  only  three  or  four 
months,  before  a  fatal  termination  takes  place ;  and  it  is  probable 
that  many  cases  of  supposed  cancer  of  the  stomach,  in  which  the 
patient  survived  for  many  years,  were  really  chronic  ulceration. 

Chronic  Ulceration  implicating  branches  of  the  Pneumo gastric. 

CASE  XLII.  Chronic  Ulcer  of  the  Stomach.  Phthisis.  Branches  of  the 
Pneitmogastric  Nerves  involved. — Eliza  B — ,  set.  21,  was  admitted  into 
Guy's  Hospital  October  13,  1858.  She  had  enjoyed  good  health  till  she  was 
fifteen  years  of  age,  when  her  health  failed.  She  was  then  obliged  to  leave 
her  situation  as  a  nursery-maid,  on  account  of  weakness,  and  pain  in  the  chest. 
At  sixteen,  menstruation  commenced,  and  continued  regularly  till  eighteen 
months  before  admission,  but  from  that  time  there  had  been  amenorrhoea. 
She  was  anaemic,  emaciated,  and  had  a  dark  areola  around  the  eyes.  The 
respiratory  murmur  was  feeble  at  the  apices ;  the  heart  sounds  were  normal. 
She  complained  of  pain  frequently  recurring  in  the  hypochondriac  and  lumbar 
regions  ;  of  a  feeling  of  distension  and  pain  after  taking  food,  and  of  a  sensa- 
tion as  of  a  weight  rolling  when  she  turned  on  her  right  side,  the  left  being 
the  side  on  which  she  could  recline  most  easily.  The  appetite  was  bad,  the 
bowels  were  regularly  open  ;  she  slept  but  little ;  the  urine  was  normal. 
Various  remedies  besides  steel  and  cod-liver  oil  were  given,  and  she  left  the 
hospital  for  a  short  time,  but  was  readmitted  on  March  16,  1859.  She  was 
then  extremely  blanched,  much  emaciated,  and  had  a  dejected  countenance. 
She  generally  sat  up  in  bed,  inclining  towards  the  left  side,  for  it  produced 
pain  to  turn  on  the  right  side.  There  was  no  evidence  of  disease  in  the  chest 


ORGANIC  DISEASES  OF  THE  STOMACH.          155 

found  after  careful  examination  ;  the  respiration  was  30 ;  the  chest  was  reso- 
nant ;  and  the  respiratory  sounds  were  feeble,  but  otherwise  healthy.  She 
had  vague  pain  in  all  parts  of  the  body,  especially  in  the  shoulder ;  the  spine 
was  tender  everywhere,  and  unusually  prominent  from  the  wasting  of  the 
muscles.  The  abdomen  was  rather  distended,  apparently  from  flatus.  In 
the  epigastric  region  there  was  a  hard  swelling,  tender  on  pressure,  and  tym- 
panitic.  When  in  great  pain  at  this  distended  part,  if  compression  was  made, 
the  swelling  disappeared,  and  the  pain  was  relieved.  On  deeper  pressure  in 
the  epigastric  region,  a  hard,  resisting  sensation  was  communicated.  The 
superficial  abdominal  veins  were  distinct.  Opium,  chloroform,  chlorodyne, 
cod-liver  oil,  etc.,  were  administered,  with  partial  relief. 

On  May  oth  she  was  transferred  to  my  care,  and  was  then  greatly  emaci- 
ated ;  she  suffered  constant  severe  pain  in  the  epigastrium,  and  in  the  left 
shoulder,  and  the  pain  was  worse  after  taking  food,  which  also  produced 
slight  nausea.  She  had  much  flatulence,  but  no  vomiting ;  the  bowels  were 
never  acted  upon  without  medicine  or  enema.  The  heart's  action  was  rapid ; 
the  rythm  regular  ;  the  pulse,  120,  was  compressible.  The  abdomen  was  firm 
and  somewhat  enlarged.  The  pain  increased  in  severity,  and  sometimes  be- 
came of  an  agonizing  character ;  it  was  somewhat  relieved  by  medicines,  as 
by  opium,  morphia,  henbane,  aconite,  creasote,  etc.  The  symptoms  con- 
tinued with  varying  severity  till  the  end  of  July,  but  in  August  symptoms  of 
phthisis  began  to  develop  themselves ;  the  right  side  became  dull,  and  indu- 
bitable signs  of  disorganization  at  the  apex  were  present.  The  patient  began 
to  cough  and  expectorate,  and  became  extremely  emaciated.  Scarcely  any 
nourishment  was  taken,  but  she  lingered  till  October  10th. 

On  inspection,  the  right  pleura  was  universally  adherent ;  the  left  partially 
so.  The  right  lung  was  extensively  disorganized,  and  contained  a  large 
cavity  in  the  upper  lobe,  and  much  tubercular  deposit  in  the  lower.  The 
cavity  was  very  large  and  ragged,  and  had  apparently  extended  rapidly. 
The  left  lung  was  nearly  healthy,  so  also  the  heart.  On  opening  the  abdo- 
men, the  stomach  was  seen  to  be  closely  adherent  to  the  left  lobe  ot  the  liver 
at  its  under  part.  The  stomach  appeared  to  be  thus  hooked  up  in  the  cen- 
tral part,  and  presented  an  hour-glass  contraction.  This  adhesion  of  the 
smaller  curvature  of  the  stomach  and  of  the  posterior  surface  of  the  liver  was 
so  firm  that  it  was  impossible  to  separate  the  two  organs.  The  liver  also 
contained  much  fibrous  tissue.  On  attempting  the  removal  of  these  viscera, 
it  was  found  that  the  pancreas  also  was  closely  involved  in  the  adhesions. 
By  opening  the  stomach  along  its  greater  curvature,  a  large  chronic  ulcer 
was  found  to  be  situated  at  the  middle  of  the  lesser  curvature.  It  was  2^ 
inches  in  length,  and  2  in  breadth,  and  had  completely  healed,  there  being 
no  sign  of  recent  action  about  it.  It  had  a  raised,  firm  edge,  and  its  floor  was 
formed  by  tough,  fibrous  tissue  upon  the  liver  and  pancreas,  the  coats  of  the 
stomach  having  been  entirely  destroyed  at  that  part  by  the  ulceration.  The 
pneumogastric  nerves  on  both  sides  terminated  in  the  fibrous  tissue  which 
bounded  the  ulcer.  The  mucous  membrane  was  elsewhere  healthy. 

The  symptoms  in  this  case  advanced  very  slowly  to  a  fatal  termi- 
nation, and  nearly  six  years  elapsed  between  the  onset  of  the  disease 
and  the  death  of  the  patient.  There  was  no  haematemesis  at  any 
period,  and  the  most  prominent  symptoms  were  anaemia,  gradually 
increasing  emaciation,  and  pain  in  the  left  side,  which  became  exceed- 
ingly severe.  The  pain  was  at  times  agonizing,  and  was  unrelieved 
by  any  form  of  anodyne  medicine  ;  the  manner  in  which  the  branches 
of  the  pneumogastric  nerve  were  involved  in  the  dense  fibrous  tissue 


156  ORGANIC    DISEASES    OF    THE    STOMACH. 

at  the  edges  of  the  ulcer  afforded  an  explanation  of  the  suffering. 
The  position  of  greatest  ease,  however,  was  that  in  which  fluids  grav- 
itated from  the  ulcer,  namely,  the  position  assumed  in  leaning  for- 
wards and  towards  the  left  side,  thus  far  confirming  the  statement  of 
Dr.  Osborne.  Vomiting  was  not  a  prominent  sign  of  disease.  For 
some  months  the  general  symptoms  were  those  of  phthisis ;  and,  in 
fact,  towards  the  close,  symptoms  of  affection  of  the  lungs  were  rap- 
idly developed.  In  reference  to  the  etiology  of  the  phthisis,  it  is  an 
interesting  question  whether  irritation  of  the  gastric  branches  of  the 
pneumogastric  nerve  had  anything  to  do  with  the  production  of  dis- 
ease, at  the  termination  of  the  pulmonary  branches,  or  whether  the 
phthisical  mischief  was  produced  by  the  general  impairment  of  nu- 
trition. 

CASE  XLIII.  Chronic  Ulceration  of  the  Stomach,  involving  the  Pneumo- 
gastric Nerve.  Atrophy  of  the  Left  Lobe  of  the  Liver.  Death  from  Ex- 
haustion— E.  S — ,  set.  32,  hud  been  a  widow  for  nine  years.  Four  years 
before  admission  into  Guy's  Hospital  she  had  an  attack  of  hoc-matemesis,  but 
her  health  improved,  and  she  continued  in  her  situation  as  housemaid.  Two 
years  later  she  had  a  similar  attack,  and,  six  months  later,  severe  pain  at  the 
region  of  the  stomach  came  on.  The  pain  continued  for  a  few  days,  and  was 
much  relieved  by  vomiting  of  blood.  A  similar  attack  came  on  after  admis- 
sion. Great  weakness,  with  severe  pain  in  the  stomach,  were  the  principal 
symptoms ;  the  pain  extended  to  the  back,  and  was  of  a  paroxysmal  charac- 
ter ;  and  food  was  very  quickly  rejected.  At  the  epigastrium,  fulness  was 
at  h'rst  felt,  but  afterwards  a  distinct  tumor.  The  vomiting  was  uncontrolla- 
ble, but  sometimes  subsided  for  several  days.  Vomiting  of  grumous  fluid 
then  came  on,  and  the  pain  at  last  became  very  severe ;  she  gradually  sank. 


Stomach  presenting  a  chronic  ulcer  ;  at  Us  upper  margin  the  pnmunogastric  nerve  Is  .shown 
extending  into  dense  fibrous  ti-sue.  The  pancreas  and  the  left  lobe  of  the  liver  formed  the  base  of 
the  ulcer  ;  the  latter  presented  fibroid  degeneration  of  its  structure. 

Inspection — The  body  was  much  emaciated  ;  there  was  no  marked  disease 
about  the  thoracic  viscera  ;  the  stomach  was  distended,  and  reached  nearly 
to  the  umbilicus.  At  the  scrobiculus  cordis  the  left  lobe  of  the  liver  was 
contracted,  and  adherent  to  the  lesser  curvature  of  the  stomach,  and  it  con- 
stituted the  tumor  which  had  been  felt  during  life.  The  stomach  contained 


ORGANIC    DISEASES    OF    THE    STOMACH.  157 

a  considerable  quantity  of  grumous  fluid,  and  at  the  lesser  curvature,  about 
half  an  inch  from  the  pylorus,  was  an  ulcer  two  inches  and  a  half  in  diame- 
ter, with  raised  everted  edges  of  mucous  membrane  and  dense  fibrous  tissue ; 
the  base  of  the  ulcer  was  smooth,  composed  of  an  albuminous  layer,  and 
formed  by  the  pancreas  and  by  the  inferior  surface  of  the  left  lobe  of  the  liver. 
The  pylorus  was  not  hypertrophied.  The  remaining  part  of  the  stomach 
appeared  healthy.  On  carefully  dissecting  the  pneumogastric  nerve  along 
the  lesser  curvature,  it  was  found  to  pass  to  the  margin  of  the  ulcer,  and  its 
fibres  were  incorporated  with  the  dense  fibrous  tissue  of  which  the  raised 
edges  of  the  ulcer  were  composed. 

The  continued  suffering,  and  the  daily  rejection  of  food,  at  length 
completely  exhausted  the  strength  of  the  patient,  and  were  the  cause 
of  her  death  ;  and  although  the  pylorus  was  free  from  obstruction, 
and  no  hypertrophic  change  was  evident  in  the  muscular  coat  of  the 
stomach  after  death,  the  symptoms  were  explained  by  the  manner 
in  which  the  branches  of  the  pneumogastric  nerve  were  involved  in 
the  dense  edges  of  the  ulcer. 

The  attack  of  haematemesis  four  years  before  admission  into  the 
hospital,  showed  the  chronic  character  of  the  disease;  and  as  the 
ulceration  slowly  extended  into  the  surrounding  vessels,  the  effu- 
sions of  blood  were  repeated  ;  but  intervals  of  reparative  action  prob- 
ably took  place,  for  we  find  that  there  were  periods  during  which  the 
more  severe  symptoms  were  relieved,  and  the  character  of  the  ulcer, 
as  shown  by  its  general  and  microscopical  appearances,  warranted 
such  a  conclusion. 

The  left  lobe  of  the  liver  was  small  and  atrophied,  and  its  section 
presented  several  large  vessels  surrounded  by  contractile  tissue,  with- 
out any  intervening  gland-structure.  Chronic  change  had  extended 
into  this  part  of  the  gland,  and  the  obliteration  of  the  vessels  had  led 
to  the  atrophy  of  the  whole  left  lobe. 

Ulceration  icith  Perforation. 

CASE  XLIV.  Chronic  Ulceration  of  the  Stomach,  with  Painter's  Colic. 

Perforation George  O — ,  set.  28,  was  admitted  into  Guy's  Hospital  Feb. 

22d,  and  died  April  16th.  He  was  a  married  man,  of  anaemic  appearance, 
but  with  dark  hair.  For  ten  years  he  had  been  a  painter,  but  previously  he 
had  employed  himself  as  a  publican,  and  he  had  then  drank  freely.  Except 
an  attack  of  fever  several  years  before,  he  had  been  in  good  health  till  nine 
months  before  admission,  when  he  was  seized  with  colic,  which  came  on  with 
vomiting,  obstinate  constipation,  and  severe  griping  pain  at  the  umbilicus ; 
from  that  time  he  lost  flesh,  and  had  constant  pain  in  various  parts  of  the 
abdomen  ;  the  bowels  became  constipated,  and  he  suffered  from  pain  between 
the  shoulders.  A  fortnight  before  admission  he  had  haematemesis,  and  he 
became  very  anaemic ;  this  condition  persisted  till  his  application  at  Guy's, 
when  the  tongue  was  pale  and  the  respiration  easy;  there  was  griping  pain 
also,  in  the  abdomen,  and  constipation  ;  but  the  abdomen  was  supple,  and  no 
disease  could  be  detected  on  palpation.  Compound  Soap  pill,  gr.  v.,  was 
given  every  six  hours. 

On  Feb.  29th Vomiting  of  grumous  matter  came  on  ;  an  enema  was  ad- 
ministered, and  an  electo-galvanic  current  applied  to  the  spine  and  abdomen  ; 
the  galvanism  produced  some  uneasiness. 


158  ORGANIC    DISEASES    OF    THE    STOMACH. 

On  March  3d. — There  was  great  pain  in  the  abdomen,  vomiting  of  grumous, 
coffee-ground  substance ;  rapid  prostration  came  on,  and  death  took  place  in 
a  few  hours. 

Inspection,  twenty-nine  hours  after  death — On  opening  the  peritoneal 
cavity  it  was  found  to  contain  a  considerable  quantity  of  gas  ;  and  grumous 
matter  was  extravasated  from  the  stomach.  Upon  raising  the  left  lobe  of 
the  liver  an  opening,  about  the  size  of  a  pea,  was  observed  in  the  lesser  cur- 
vature of  the  stomach;  the  mucous  membrane  was  generally  thickened,  and 
about  half  an  inch  from  the  pylorus,  near  the  lesser  curvature,  was  an  oval 
ulcer,  about  three  inches  by  two  in  size,  with  raised  and  everted  edges  ;  the 
floor  of  the  ulcer  was  formed  by  the  pancreas,  covered  by  white  fibrous  tissue  ; 
the  opening  before  mentioned  was  at  the  anterior  part  of  this  ulcer.  The 
colon  contained  a  large  quantity  of  scybala. 

There  was  considerable  difficulty  in  the  diagnosis  of  this  case;  the 
evident  indication  of  colic,  in  a  painter  of  intemperate  habits,  ren- 
dered the  symptoms  of  ulceration  of  the  stomach  more  than  usually 
obscure.  The  attack  of  hoematemesis  might  have  been  attributed 
either  to  ulceration  or  congested  portal  circulation  :  but  the  vomiting 
of  coffee-grounds  substance  indicated  the  slow  effusion  of  blood;  and 
it  afforded  a  very  characteristic  symptom  of  chronic  organic  disease. 
The  immediate  cause  of  the  perforation  was  not  apparent ;  but, 
although  we  could  not  affirm  that  the  muscular  contraction  produced 
by  the  galvinism  was  in  any  manner  the  cause  of  the  suddenly  fatal 
issue,  still,  if  the  chronic  ulcer  of  the  stomach  had  been  as  prominently 
before  the  mind  as  the  lead  colic,  it  is  probable  that  the  use  of  gal- 
vanism would  not  have  been  directed. 

CASK  XLV.  Perforating  Ulcer  of  the  Stomach  with  a  second  small 
Chronic  Ulcer  in  the  same  organ — Harriet  B — ,  aet.  22,  a  single  woman,  a 
milliner,  who  worked  in  the  city,  but  resided  at  Bethnel  Green,  was  stated 
to  have  enjoyed  good  health,  with  the  exception  of  occasional  pain  and  other 
uneasy  sensations  in  the  gastric  region,  but  she  had  not  any  s  ckness,  and 
she  continued  at  work.  The  bowels  were  generally  regular.  On  Friday, 
Oct.  20th,  after  eating  at  about  3  P.M.  a  full  meal  of  anchovies  and  bread, 
she  was  seized  with  violent  vomiting,  followed  by  most  intense  pain,  which 
commenced  in  the  left  hypochondriac  region,  and  gradually  extended  over 
the  abdomen.  She  said  that  the  pain  commenced  by  something  giving  way 
in  her  side.  When  seen,  about  9  P.  M.,  she  was  in  a  state  of  great  prostra- 
tion, and  she  died  at  11  A.  M.  on  the  21st,  twenty  hours  from  the  commence- 
ment of  the  attack. 

The  body  was  well  nourished.  On  opening  the  abdomen,  the  viscera  were 
found  distended  and  covered  with  a  coat  of  recent  lymph,  and  with  some 
castor  oil,  which  had  been  administered  by  the  friends  shortly  after  the 
attack.  In  the  stomach  there  were  two  ulcers,  one  with  raised  and  rounded 
edges,  about  half  an  inch  in  diameter,  extending  to  the  muscular  coat,  the 
other  about  the  same  size,  but  with  a  smaller  opening  in  the  muscular,  and 
a  round,  smooth,  small  punch-hole  opening  perforating  the  peritoneal  sac. 
Both  were  situated  at  the  lesser  curvature,  and  the  latter,  in  which  was  the 
peritoneal  perforation,  was  towards  the  posterior  part.  The  remaining  viscera 
appeared  healthy. 

This  case  was  peculiarly  interesting:  1st,  in  presenting  two  ulcers 
in  the  stomach,  but  in  different  stages,  the  one  resembling  ordinary 


ORGANIC  DISEASES  OF  THE  STOMACH.          159 

chronic  ulcer  with  thickened  edges,  the  other  having  the  appearance 
of  but  slight  action  around  it;  2d,  in  the  early  age  of  the  patient, 
twenty-two,  and  the  slight  character  of  the  symptoms,  namely  pain 
but  no  sickness  ;  although  an  ulcer  existed  in  the  stomach,  dyspepsia 
was  the  only  precursor  of  the  fatal  perforation,  and  she  considered 
herself  in  good  health,  and  continued  at  work ;  3d,  in  the  sedentary 
employment,  constrained  position,  irregular  meals,  uncertain  hours, 
and  probably  only  scanty  fare,  all  tending  to  impair  nutrition,  and 
act  as  causes  of  this  fatal  malady;  4th,  in  the  occurrence  of  the  per- 
foration, as  is  usually  the  case,  after  a  meal ;  5th,  in  the  pain  com- 
mencing at  the  hypochondriac  region,  for  this  is  not  always  the  case, 
and  we  cannot  thereby  ascertain  at  all  times  the  seat  of  perforation : 
sometimes,  even,  the  position  of  the  pain  suggests  caeca!  instead  of 
gastric  disease ;  and  6thly,  in  showing  the  folly  of  at  once  giving  a 
purgative  draught,  for  the  castor  oil  was  here  found  floating  in  the 
peritoneal  cavity. 

CASE  XL VI.  Chronic  Ulceration.  Death  from  Perforation.  A  man, 
set.  37,  had  been  subject  to  dyspepsia,  constipation,  and  general  abdominal 
uneasiness,  but  he  had  had  no  vomiting ;  intense  pain  came  on  suddenly, 
and  he  died  in  a  few  hours. 

In  the  stomach  a  circular  ulcer  was  found  about  the  size  of  a  five-shilling 
piece,  the  edges  were  rounded,  and  the  mucous  membrane  was  more  exten- 
sively destroyed  than  the  muscular ;  the  base  of  the  ulcer  was  formed  by  the 
pancreas  and  by  condensed  cellular  tissue  ;  and  quite  at  its  upper  margin,  be- 
low the  left  lobe  of  the  liver,  there  was  a  small  perforation,  which  had  led 
to  general  peritonitis.  The  microscopical  examination  of  the  ulcer  showed 
it  to  be  of  a  simple  inflammatory  character. 

The  absence  of  hsematemesis,  of  vomiting,  and  of  other  symptoms 
of  gastric  ulcer,  except  dyspepsia,  was  remarkable  in  this  case,  for  the 
ulcer  was  of  large  size,  and  was  not  of  recent  formation. 

CASK  XLVII.  Chronic  Ulcer  of  the  Stomach.  Perforation — Mary 
C — ,  aet.  21,  was  admitted  August  28th,  1858,  about  noon,  and  died  in  ten 
minutes.  She  had  been  in  a  situation  near  the  hospital,  and  had  sutfered 
from  vomiting  occasionally  for  five  years,  but  had  never  had  haematemesis. 

Inspection  was  made  about  three  hours  after  death.  There  was  general 
peritonitis.  In  the  stomach  there  were  two  ulcers,  each  about  three-eighths 
of  an  inch  in  diameter  ;  both  were  situated  at  the  lesser  curvature,  the  one 
at  the  anterior,  the  other  at  the  posterior  part  of  the  stomach.  Their  edges 
toward  the  stomach  were  thickened  and  bevelled ;  the  anterior  one  presented 
a  small  punch-hole  opening  extending  into  the  peritoneum,  which  had  led  to 
the  fatal  peritonitis.  The  posterior  one  had  also  perforated  all  the  coats,  but 
extravasation  had  been  prevented  by  the  adhesions.  The  other  portions  of 
the  mucous  membrane  of  the  stomach  were  healthy,  presenting  only  slight 
injection  ;  the  remaining  viscera  were  healthy. 

In  this  case  there  had  been  evidence  of  disorder  of  stomach  for 
several  years ;  and  the  appearance  of  the  ulcer  also  indicated  chronic 
action  in  its  thickened  edges,  but  there  had  been  no  vomiting  of  blood. 
The  ulcers  on  opposed  surfaces  of  the  stomach  probably  arose  from 
the  two  surfaces  coming  into  contact. 


160  ORGANIC    DISEASES    OF    THE    STOMACH. 

CASE  XLVIII.  Perforating  Ulcer  of  the  Stomach — A  servant  girl,  ret. 
27,  residing  in  the  Borough,  was  suddenly  seized  with  severe  pain  in  the 
abdomen  ;  collapse  came  on,  and  death  followed  in  twenty-four  hours.  On 
inspection  a  round  ulcer  was  found  on  the  anterior  surface  of  the  stomach  ; 
on  the  mucous  surface  it  was  half  an  inch  in  diameter,  but  on  the  peritoneal 
only  a  quarter  of  an  inch,  and  there  was  very  little  thickening.  Its  perfor- 
ation into  the  peritoneum  had  set  up  fatal  peritonitis.  Other  portions  of 
the  mucous  membrane  of  the  stomach  were  partially  dissolved.  Remaining 
viscera  were  healthy. 

This  was  one  of  the  instances  in  which  there  was  very  little  indi- 
cation of  disease  prior  to  the  fatal  attack,  and  the  appearance  of  the 
stomach  after  death  showed  an  absence  of  thickening,  and  of  chronic 
action. 

CASE  XLIX — A  remarkable  case,  in  which  an  ulcer  of  the  stomach  ex- 
isted, and  in  which  perforation  was  apparently  produced  by  the  straining 
consequent  on  violent  vomiting,  occurred  under  the  care  of  Sir  William  Gull 
in  a  hospital  patient  in  I860.  A  young  man,  aet.  21,  was  seized  three  weeks 
before  his  heath  with  griping  pain  in  the  abdomen,  followed  by  intense  pain 
and  obstinate  constipation.  There  was  severe  vomiting.  Two  bands  were 
found  in  the  peritoneum  passing  upwards  from  the  caecum,  one  to  the  trans- 
verse colon,  strangulating  the  intestines  which  had  slipped  beneath  it,  the 
other  passed  to  the  pelvis. 

In  the  stomach,  about  one-third  from  the  oesophagus  towards  the  pylorus 
and  an  inch  from  the  lesser  curvature,  was  an  ulcer,  which  had  perforated  the 
peritoneum  and  had  set  up  intense  peritonitis.  The  opening  through  the  serous 
membrane  was  smaller  than  that  in  the  mucous  membrane.  There  was  no 
thickening  of  the  edges  of  the  ulcer. 

CASE  L.  Chronic  Ulcer  of  the  Stomach.  Perforation  of  all  the  coats 
except  the  Peritoneal.  Fatal  Peritonitis — (Reported  by  Mi\  A.  W.  A. 
Evans.)  William  M — ,  aet.  29,  a  policeman,  was  admitted  into  Guy's  Hos- 
pital, October  28th,  1859,  under  Dr.  Addison's  care.  He  had  been  in  the 
police  force  for  six  weeks,  when  he  was  seized  with  pain  about  the  scorbi- 
culus  cordis,  with  vomiting,  which  came  on  about  an  hour  after  food  had 
been  taken.  There  was  pain  also  at  the  right  shoulder,  and  a  little  blood 
was  found  in  the  vomited  matter,  but  no  sarcinae.  He  had  suffered  habitually 
from  constipation.  Three  years  previously  he  had  had  a  similar  attack, 
from  which,  however,  he  recovered  in  three  months.  He  afterwards  enjoyed 
good  health,  although  he  had  vague  and  intermittent  pains  in  the  epigastrium. 
He  was  a  tall,  sallow,  and  anaemic  man,  and  on  admission  suffered  from  rather 
severe  pain  at  the  epigastric  region,  but  nothing  could  be  felt  on  tactile  ex- 
amination. He  stated  that  he  had  passed  dark-colored  stools ;  the  tongue 
was  large  and  white ;  the  pulse  88.  Magnesia  mixture,  with  hydrocyanic 
acid,  was  prescribed  three  times  a  day.  A  castor-oil  injection  was  admin- 
istered at  night,  and  beef  tea  and  arrowroot  allowed.  A  small  blister  was 
afterwards  applied  to  the  scrobiculus  cordis,  and  ^ij  of  sherry  wine,  with  two 
eggs,  etc.,  were  ordered.  On  November  2d  nitrate  of  bismuth  was  given, 
with  mucilage  mixture.  The  bowels  then  became  constipated,  and  the  mag- 
nesia mixture  was  repeated  with  dilute  hydrocyanic  acid,  tincture  of  opium, 
and  of  lavender.  On  the  4th  he  passed  a  black  evacuation,  but  the  consti- 
pation continued.  On  the  14th  gr.  xv  of  colocynth  and  calomel  were  given, 
and  a  castor-oil  injection  administered,  which  acted  very  freely  on  the  bowels. 
On  the  16th,  severe  pain  came  on  in  the  abdomen;  he  became  collapsed, 


ORGANIC    DISEASES    OF    THE    STOMACH.  161 

and  had  vomiting,  with  excessive  tenderness  of  the  abdomen  ;  a  grain  of 
opium  was  then  given  every  six  hours;  hut  on  the  17th  he  was  evidently- 
sinking,  and  died  at  9  P.  M.  On  inspection  the  peritoneum  was  found  to  be 
universally  inflamed,  and  the  intestines  were  glued  together  by  recent  lymph  ; 
older  adhesions  were  found  between  the  stomach  and  the  parietes  at  the  supe- 
rior part  of  the  abdomen.  The  stomach  was  slightly  hour-glass  in  form  ;  and 
about  one  and  a  half  inches  from  the  pylorus  on  its  posterior  aspect  was  a 
chronic  ulcer ;  all  the  coats  were  destroyed,  and  the  pancreas  formed  the 
base  of  the  ulcer,  which  was  two  inches  in  diameter.  The  mucous  coat  was 
more  extensively  destroyed  than  the  muscular.  A  smaller  ulcer,  directed 
anteriorly,  united  with  the  posterior  and  larger  one,  its  base  was  formed  by 
delicate  fibro-cellular  tissue  and  peritoneum  ;  this  thinned,  almost  perforated 
portion,  was  a  quarter  of  an  inch  in  diameter,  and  at  its  centre  was  a  trans- 
parent spot,  only  one-eighth  of  an  inch  across ;  water,  however,  did  not 
exude.  The  perforation  was  not  complete,  but  there  was  no  doubt  that  suffi- 
cient transudation  had  taken  place  to  produce  the  fatal  peritonitis.  The 
thoracic  and  other  viscera  were  healthy. 

The  condition  of  the  ulcers  in  the  stomach  was  peculiar;  two  ulcers 
had  become  united,  but  the  posterior  portion  was  of  older  formation, 
and  had  a  firm  base  of  pancreatic  tissue;  not  so,  however,  the  ante- 
rior one ;  its  base  consisted  of  fibro-cellular  tissue  and  peritoneum, 
but  the  serous  membrane  was  still  entire.  In  typhoid  ulceration  of 
the  intestines  we  have  several  times  observed  peritonitis  produced 
when  the  peritoneum  remained  entire,  transudation  having  taken 
place  without  complete  perforation,  and  it  is  probable  that  a  similar 
occurrence  ensued  in  this  instance.  The  case  illustrates,  also,  the 
caution  that  should  be  used  in  the  administration  of  purgative  medi- 
cines. 

Chronic  Ulceration  leading  to  Abscess. 

CASE  LI.  Perforation  of  the  Stomach.  Local  Suppuration  in  the  Peri- 
toneum. Pleuro-pneumonia. — M.  A.  B — ,  set.  33,  was  admitted  into  Guy's 
Hospital,  under  my  care,  September  20th,  1860.  She  was  tall  and  stout, 
and  stated  that  till  the  18th  she  had  enjoyed  good  health  ;  at  2  A.  M.  of  that 
day  she  had  been  seized  with  severe  pain  in  the  left  side,  which  continued 
till  admission. 

On  the  21st  she  was  in  less  pain,  and  the  countenance  was  less  distressed ; 
the  tongue  had  white  fur  on  it,  and  was  rather  dry ;  deep  inspiration  pro- 
duced severe  pain  in  the  left  side,  but  no  friction  sound  could  be  heard  ;  air 
entered  the  lower  lobe  of  the  left  lung  very  imperfectly;  and,  in  fact,  respi- 
ration was  scarcely  audible  either  in  front  or  behind  on  the  left  side.  There 
was  no  abnormal  sound  with  the  heart ;  the  pulse  was  compressible,  and 
the  skin  hot.  The  resident  medical  officer  had  ordered  gr.  xv  of  colocynth 
and  calomel,  and  pills  twice  a  day,  containing  calomel,  antimony,  and  opium. 

On  the  22d  she  still  complained  of  severe  pain  in  the  side  ;  there  was  dul- 
ness  at  the  base  of  the  left  lung,  and  scarcely  any  air  entered  that  lung ;  the 
skin  was  hot ;  the  tongue  was  dry  and  furred ;  the  pulse  was  compressible  ; 
the  bowels  were  opened  freely.  She  was  ordered  to  be  cupped  on  the  left 
side  to  |vj  ;  to  take  soap  and  opium  gr.  v  every  night ;  and  acetate  of  ammo- 
nia three  times  a  day. 

On  the  24th  the  pain  in  the  side  was  much  less  severe,  but  she  was  still 
very  ill,  complaining  of  tenderness  of  the  abdomen  ;  the  tongue  had  a  whitish 
11 


162  ORGANIC    DISEASES    OF    THE    STOMACH. 

fur.  The  abdomen  was  supple,  not  tympanitic,  but  there  was  tenderness  at. 
the  lower  part.  She  stated  that  in  the  previous  week,  immediately  after 
menstruation,  she  had  been  exposed  to  cold,  and  that  then  the  pain  came  on. 
Carbonate  of  ammonia  was  given  three  times  a  day,  and  the  opium  pill  con- 
tinued. 

On  the  25th  she  complained  of  an  offensive  taste  in  the  mouth,  and  of  in- 
creased pain  in  the  left  hypochondriac  region,  but  she  bore  considerable 
pressure  without  aggravation  of  her  suffering ;  the  tongue  was  furred ;  the 
mouth  was  clammy  ;  the  pulse  compressible,  and  slightly  excited.  She  very 
much  desired  to  have  soda  water,  and  was  ordered  effervescing  mixture,  with 
carbonate  of  magnesia,  gr.  x,  every  four  hours,  and  wine  ^vj. 

On  the  29th  she  was  still  distressed  with  an  offensive  ta*te  in  the  mouth  ; 
the  tongue  was  furred ;  there  was  no  tenderness  of  the  abdomen,  nor  distress 
in  breathing.  Opium  was  given  night  and  morning,  and  soda  water  occa- 
sionally. 

On  the  30th  she  was  seized  with  eructation,  and  vomiting  of  thin  offensive 
pus,  to  use  the  words  of  the  sister  of  the  ward,  as  if  an  abscess  had  broken  ; 
she  became  exceedingly  prostrate,  and  died  on  the  2d  October  at  9.50  A.  M. 

Inspection  on  the  same  day  at  2.30  P.  M.  The  pleura  was  adherent  at 
the  lower  lobes  of  both  lungs,  which  were  in  a  state  of  lobular  inflammation. 
The  heart  was  healthy.  The  liver  was  pale,  and  it  extended  nearly  to  the 
crest  of  the  ilium ;  it  was  very  fatty,  and  weighed  6  Ibs.  On  the  left  side 
there  was  a  large  abscess  in  the  peritoneum  bounded  by  the  spleen,  the  left 
lobe  of  the  liver,  and  the  stomach.  The  walls  of  the  abscess  were  covered  with 
a  layer  of  greenish-yellow  lymph,  and  the  abscess  contained  about  two  pints 
of  gray  offensive  pus.  The  abscess  communicated  with  the  stomach  by  a 
small  punch-hole  perforation,  situated  about  the  middle  of  the  lesser  curva- 
ture of  the  stomach  on  the  anterior  aspect.  The  edges  of  the  ulcer  were 
bevelled  internally,  but  they  were  not  thickened.  The  mucous  membrane  of 
the  stomach  was  thickened  and  ecchymosed  in  patches ;  there  was  some  con- 
traction of  the  mucous  membrane  of  the  stomach  opposite  the  ulcer  over  the 
pancreas,  as  if  from  the  cicatrix  of  a  former  ulcer.  The  kidneys  were  pale  ; 
the  intestines  and  ovaries  were  healthy. 

The  diagnosis  of  this  case  was  obscure :  on  admission,  there  ap- 
peared to  be  diaphragmatic  pleurisy,  but  afterwards  it  was  evident 
that  the  disease  was  below,  riot  above,  the  diaphragm.  There  was 
an  absence  of  the  ordinary  signs  of  peritonitis,  namely,  tenderness 
and  distension  of  the  abdomen ;  still,  there  was  pain  of  moderate 
degree  in  the  lower  part  of  the  abdomen,  especially  on  the  left  side. 
There  cannot  indeed  be  a  greater  proof  of  the  absence  of  the  ordi- 
nary signs  of  peritonitis  than  that  a  gentleman  of  great  experience 
ordered,  in  rny  absence,  free  purgatives  of  colocynth  and  calomel. 
The  patient  was  very  restless,  but  her  principal  complaint  was  of 
the  offensive  taste  in  the  mouth,  and  she  incessantly  begged  to  have 
soda  water.  The  adhesions  had  localized  the  inflammation,  and 
there  was  none  of  the  collapse  which  marks  perforation  into  the 
general  cavity  of  the  peritoneum.  For  several  days  the  suppuration 
increased  in  the  abscess,  but  it  evidently  communicated  with  the 
stomach,  and  the  decomposition  of  its  contents  led  to  the  offensive 
character  of  the  breath  which  distressed  the  patient  so  much.  It  is 
probable  that  the  pneumonia  arose  from  pyaemia ;  and  it  did  not 
come  on  till  a  short  time  before  death.  The  sudden  discharge  of 


ORGANIC  DISEASES  OF  THE  STOMACH.          163 

pus  only  a  few  hours  before  death  indicated  the  rupture  of  an  abscess ; 
but  it  was  even  then  very  doubtful  whether  it  proceeded  from  a 
thoracic  or  abdominal  source. 

CASE  LII.  Chronic  Ulceration  of  the  Stomach,  extending  to  the  Dia- 
phragm, and  simulating  Pneiimothorax. — Barbara — ,  aet.  39,  was  a  married 
woman,  who  for  eighteen  months  had  suffered  from  symptoms  of  dyspepsia  or 
chronic  gastritis,  from  pain  between  the  shoulders  and  at  the  epigastrium, 
and  from  vomiting.  Two  days  before  admission  she  was  seized  with  intense 
pain  in  the  left  side  and  shoulder,  and  she  had  urgent  dyspnoea.  On  ex-ami- 
nation  at  the  base  of  the  left  lung  there  was  resonance,  amphoric  breathing 
metallic  tinkling,  and  segophony.  She  died  twenty  days  alter  the  attack  of 
dyspnoea. 

Dr.  Barlow's  diagnosis  was  confirmed ;  there  was  pleurisy  on  the 
left  side,  and  a  large  peritoneal  abscess,  which  communicated  by  two 
openings  with  the  lesser  curvature  of  the  stomach — one  near  the 
O3sophagus,  capable  of  admitting  the  middle  finger,  and  another, 
smaller,  near  the  anterior  wall.  The  abscess  was  bounded  bv  the 
ribs,  spleen,  liver,  and  diaphragm,  and  by  inflammatory  adhesions  in 
a  partially  sloughing  condition.  The  pleura  in  this  case  was  not 
perforated,  so  that  the  symptoms  of  pneumothorax  were  produced 
by  the  air  in  the  peritoneal  abscess. 

The  post-mortem  examination  in  the  following  remarkable  case  is 
here  introduced  as  an  illustration!  of  perforation  of  the  stomach, 
associated  with  perforation  of  the  colon,  as  well  as  of  the  diaphragm. 
The  disease,  however,  in  the  colon  appeared  to  be  of  the  longest 
duration,  and  to  have  led  to  the  formation  of  the  fecal  abscess,  whilst 
the  perforation  of  the  stomach  was,  perhaps,  secondary,  and  from  the 
external  to  the  internal  surface. 

CASE  LIII.  Fecal  Abscess,  connected  with  the  Stomach,  the  Lung,  the 

Spleen,  and  the  Transverse  Colon Ellen  R — ,  aet.  25,  was  admitted  in  July, 

and  died  August  5th,  1847.  History  not  known,  except  that  she  had  fecal 
vomiting. 

On  inspection  the  left  lung  was  found  adherent  by  old  adhesions  ;  a  vomica 
was  found  in  the  upper  lobe,  and  gray  hepatization  existed  at  its  lower  part. 

Abdomen The  intestines  were  matted  together  by  old  adhesions;  the  liver 

also  was  adherent  to  the  stomach.  On  the  left  side  was  an  abscess  of  some 
extent,  bounded  in  front  and  to  the  outer  side  by  the  ribs,  to  the  inner  side 
by  the  stomach  and  by  the  spleen,  below  by  the  transverse  arch  of  the  colon, 
above  by  the  diaphragm  and  right  lung.  This  abscess  communicated  with  the 
chest  by  an  opening  through  the  diaphragm,  and  was  there  bounded  by  the 
lower  surface  of  the  right  lung  and  thickened  pleura.  It  communicated  also 
by  two  separate  openings  with  the  greater  curvature  of  the  stomach,  and  by 
one  opening  with  the  transverse  colon  ;  it  was  filled  with  partially  coagulated 
blood ;  the  upper  portion  of  the  spleen  was  found  sloughing  in  the  cavity  of 
the  abscess.  The  stomach  also,  and  the  transverse  colon  contained  each  of 
them  a  considerable  quantity  of  blood.  The  openings  in  the  stomach  were 
round  holes,  having  tolerably  smooth  edges,  and  the  mucous  coat,  was  not 
thickened  ;  the  peritoneal  coat  appeared  as  if  it  had  been  ruptured.  There 
were  several  ulcers  in  the  transverse  colon  which  communicated  with  the 
abscess,  and  the  bowel  was  thickened  around  them.  The  liver  was  large  and 


164  ORGANIC    DISEASES    OF    THE    STOMACH. 

fatty.  Some  of  the  mesenteric  glands  were  calcareous.  The  contents  of  the 
pelvis  were  all  bound  together  by  old  adhesions,  and  there  was  a  considerable 
quantity  of  recent  lymph  at  this  part.  Between  the  rectum  and  the  bladder 
was  an  abscess  communicating  with  the  rectum  ;  there  were  several  other 
ulcers  in  the  rectum,  and  the  whole  mucous  membrane  was  intensely  injected 
and  of  a  deep  purple  color.  There  was  strumous  ulceration  of  the  mucous 
membrane  of  the  uterus. 

CASE   LIV.    Chronic   Ulcer  of  the  Stomach.     Peritoneal  Abscess.     Per- 
foration of  the  Diaphragm.     Empyema J.  F.  L — ,  set.  G4,  a  basket  maker 

by  trade,  was  admitted  into  Guy's  Hospital,  under  Sir  William  Gull's  care, 
May  14th,  18GO.  He  had  inflammation  of  the  lungs  when  thirty  years  of  age, 
and  a  year  afterwards  he  had  rheumatic  fever.  Seven  years  before  admis- 
sion he  had  a  blow  by  a  capstan,  which  threw  him  into  the  hold  of  the  vessel, 
and  from  that  time  he  had  always  suffered  pain  on  taking  cold.  Seventeen 
or  eighteen  months  previous  to  admission  he  had  also  noticed  a  swelling  at 
the  epigastric  and  umbilical  regions,  and  he  had  nausea  and  vomiting  after 
taking  food,  but  no  blood  was  vomited.  Severe  tearing  pain  at  the  stomach 
was  produced  by  retching,  and  he  also  experienced  at  those  times  a  burning 
sensation,  which  lasted  for  twenty-four  hours.  The  swelling  had  not  increased, 
but  had  extended  more  generally  over  the  abdomen  ;  and  for  a  few  days  the 
pain  had  reached  the  loins.  For  two  weeks  he  had  felt  severe  pain  above 
the  crest  of  the  ileum  on  each  side  ;  it  came  on  after  attempting  to  work,  and 
it  passed  up  each  side  behind  the  clavicle.  The  painful  part  began  to  swell, 
and  continued  swollen  for  two  days,  but  the  swelling  afterwards  disappeared. 
From  the  commencement  of  his  illness  he  stated  that  he  had  had  a  sense  of 
tearing  whenever  he  lifted  his  left  arm  ;  and  he  had  frequently  felt  severe  pain 
below  the  last  rib  on  the  left  side  ;  the  pain  was  also  felt  in  the  lumbar  region. 
He  had  suffered  much  from  flatulence,  but  not  from  sickness ;  the  bowels 
were  generally  constipated.  He  was  a  spare  man,  with  an  anxious  expres- 
sion. The  chest  on  admission  was  normal.  The  liver  could  be  felt  in  the 
epigastric  region  ;  the  spleen  was  also  enlarged.  The  abdomen  was  increased 
in  size  ;  it  was  tender  and  tympanitic  ;  but  no  fluctuation  could  be  felt.  The 
urine  was  not  albuminous,  its  sp.  gr.  was  1020.  He  was  ordered  iodide  of 
potassium  with  the  bicarbonate  of  potash.  On  the  19th  the  pain  in  the 
abdomen  was  aggravated  so  that  he  could  scarcely  bear  the  pressure  of  the 
bedclothes;  the  bowels  were  confined.  Half  a  grain  of  opium  was  given 
twice  a  day,  and  a  simple  injection  was  administered.  During  the  afternoon 
of  the  same  day  intense  pain  came  on,  and  extended  from  the  crest  of  the 
ileum  to  the  side  of  the  thorax.  On  the  20th  he  seemed  to  be  in  severe  pain, 
and  he  suffered  from  great  dyspnoea ;  the  face  was  pallid ;  there  was  an  anxious 
expression  of  countenance  ;  and  he  had  slight  cough  and  scanty  expectoration  ; 
the  abdominal  muscles  did  not  move ;  the  base  of  the  left  lung  was  dull,  both 
anteriorly  and  posteriorly,  and  there  was  an  absence  of  any  respiratory  sound ; 
but  there  were  tactile  vibration  and  vocal  resonance.  The  abdomen  was 
tense ;  the  skin  was  hot,  but  the  extremities  cold  ;  and  he  complained  of  great 
thirst.  On  the  21st  there  was  still  great  pain  on  the  left  side  of  the  chest ;  the 
left  side  was  dull  on  percussion  except  at  the  apex  posteriorly;  there  was  an 
entire  absence  of  respiratory  murmur  and  vocal  resonance  at  the  base  of  the  left 
lung,  but  passing  upwards  the  breathing  became  bronchial,  and  higher  still 
it  became  amphoric,  with  almost  an  aegophonic  voice  and  great  resonance  on 
coughing.  The  heart  sounds  were  distinct  on  the  right  side  of  the  sternum, 
and  the  dulness  extended  as  far  as  that  part.  On  the  right  side  generally  the 
respiration  was  puerile,  and  accompanied  with  bronchial  rales ;  the  pulse  was 


ORGANIC    DISEASES    OF    THE    STOMACH.  165 

104 ;  the  tongue  moist  and  furred ;  the  bowels  were  open  ;  there  was  no 
appetite,  but  there  was  great  thirst,  and  the  breath  was  sweet.  A  blister  was 
applied ;  acetate  of  potash  with  nitric  ether  and  compound  tincture  of  cam- 
phor were  prescribed,  and  four  ounces  of  gin,  afterwards  increased  to  eight, 
were  ordered.  The  patient,  however,  rapidly  sank,  and  died  the  following 
day  at  half-past  four.  On  inspection  the  abdomen  was  enlarged.  The  left 
pleura  was  full  of  pus,  and  was  lined  with  a  flocculent  membrane ;  the  heart 
wa>  pushed  over  beyond  the  median  line,  and  the  left  lung  was  compressed. 
The  right  pleura  and  lung  were  healthy,  so  also  the  pericardium  and  the 
heart.  On  opening  the  abdomen  the  left  lobe  of  the  liver  was  found  to  be 
adherent  at  the  scrobiculus  cordis  by  firm  tissue,  and  it  had  formed  the  hard 
mass  felt  during  lite ;  the  peritoneum  generally  was  healthy.  On  drawing 
down  the  stomach,  and  removing  the  left  lobe  of  the  liver,  a  large  abscess 
was  found  between  the  stomach  and  the  diaphragm,  and  it  contained  nearly 
a  pint  of  pus.  The  abscess  was  bounded  by  the  liver  in  front  and  on  the 
right,  by  the  spleen  on  the  left,  and  by  the  pancreas  posteriorly.  In  the 
diaphragm  was  a  small  opening  about  the  size  of  a  crow-quill,  and  thus  a 
communication  had  been  formed  between  the  abscess  in  the  abdomen  and  the 
pleura.  At  the  lesser  curvature  of  the  stonjach,  and  on  its  posterior  aspect, 
was  a  chronic  ulcer  two  and  a  half  inches  long,  bounded  behind  by  dense  cica- 
trized tissue  on  the  pancreas,  but  no  perforation  could  be  detected.  The  liver 
was  fatty,  the  other  viscera  were  healthy. 

Sir  W.  Gull  correctly  diagnosed  this  case  as  one  of  chronic  disease 
of  the  stomach,  leading  to  perforation  of  the  diaphragm,  and  causing 
the  fatal  attack  of  pleurisy.  The  swelling  at  the  epigastric  region, 
accompanied  with  nausea,  vomiting,  and  "tearing  pain,"  were  strongly 
indicative  of  gastric  disease ;  but  it  was  very  doubtful  whether  the 
malady  was  of  a  cancerous  character.  It  was  doubtful,  also,  whether 
the  blow  he  received  from  a  capstan  had  anything  to  do  with  his 
subsequent  disease.  Chronic  ulceration  took  place,  perforation  of 
the  walls  of  the  stomach  followed ;  but  the  mischief  was  localized  by 
adhesions ;  suppuration  then  took  place,  beneath  the  diaphragm ; 
this  muscle  at  last  itself  became  perforated,  and  intense  pleurisy  was 
at  once  set  up  by  the  extravasation  of  pus  into  the  pleural  cavity. 

CASE  LV.  Chronic  Ulceration  of  the  Stomach.  Perforation.  A  Sinus 
extending  into  the  Left  Lung.  Gangrene.  Empyema.  Second  Chronic 

Ulcer Eliz.  F — ,  aet.  36,  had  been  treated  as  an  out-patient  for  dyspepsia, 

and  it  was  supposed  that  ulceration  of  the  stomach  existed  ;  the  prominent 
symptom  was  vomiting  of  coffee-ground  matter.  After  admission  into  the 
hospital  she  became  extremely  low  and  emaciated,  and  gradually  sank.  It 
was  then  believed  that  she  had  cancerous  disease.  She  died  October  13th, 
and  was  examined  twenty-six  hours  after  death. 

Chest The  left  pleura  contained  purulent  effusion.  The  lower  lobe  of 

the  left  lung  was  pneumonic  and  adherent  to  the  diaphragm  ;  a  vertical  sec- 
tion of  this  lobe  exhibited  an  excavation,  filled  with  dark-gray  and  tenacious 
matter,  which  exhaled  a  gangrenous  odor.  The  cavity  was  traversed  by 
pulmonary  vessels,  which,  when  placed  under  water,  had  a  curious  flocculent 
appearance  ;  a  sinus  passed  from  this  cavity,  through  several  fistulous  open- 
ings in  the  diaphragm,  into  the  stomach.  The  heart  and  pericardium  were 
normal,  except  that  the  foramen  ovale  was  open.  In  the  abdomen  there  were 
chronic  and  vascular  adhesions  between  the  viscera  and  parietes,  more  particu- 
larly about  the  right  hepatic  lobe ;  the  liver  was  situated  unusually  low  in 


166  ORGANIC    DISEASES    OF    THE    STOMACH. 

the  abdomen.  The  small  intestine  appeared  perfectly  healthy ;  the  kidneys 
were  coarse  and  their  tunics  adherent.  The  liver  and  gall-bladder  were 
healthy. 

On  opening  the  stomach,  along  the  greater  curvature,  an  aperture  of  a 
circular  figure  was  discovered  in  its  walls,  the  circumference  of  which,  with 
the  exception  of  a  small  aperture  at  its  upper  border,  was  very  firmly  adhe- 
rent to  the  under  surface  of  the  left  lobe  of  the  liver.  This  appearance,  the 
remains  of  old  ulceration,  was  situated  in  the  region  of  the  lesser  curvature 
of  the  stomach.  From  the  perforation  in  the  ulcerated  walls  of  the  stomach 
a  sinus  passed  upwards,  bounded  upon  the  left  by  the  spleen,  on  the  right  by 
the  left  lobe  of  the  liver,  and  behind  by  the  pancreas  and  small  omentum  ; 
above,  it  extended  to  the  diaphragm,  which  was  perforated  by  several  fora- 
mina, and  the  sinus  communicated  with  a  cavity  in  the  inferior  lobe  of  the 
left  lung;  the  surfaces  of  the  organs  bounding  this  sinus  were  tinged  with  a 
dark-gray  hue.  The  opening  from  the  ulcer  in  the  stomach  was  valvular, 
and  was  situated  under  its  superior  border.  The  stomach  contained  dark, 
almost  black,  thick,  viscid  fluid ;  there  was  also  a  second  chronic  ulcer  near 
the  pyloric  extremity  of  the  stomach. 

The  diagnosis  of  this  case  was  obscure ;  the  earlier  symptoms 
indicated  ulceration  of  the  stomach,  but  the  unusual  prostration  led 
to  the  idea  that  the  disease  was  of  a  cancerous  character.  The  dis- 
ease commenced  in  the  stomach,  and  the  ulcer  at  the  lesser  curva- 
ture led  to  perforation ;  the  aperture,  however,  was  at  the  posterior 
aspect,  and  it  was  also  surrounded  by  adhesions,  so  that  it  passed 
into  the  structures  between  the  diaphragm  and  the  stomach  without 
leading  to  general  peritonitis.  Circumscribed  suppuration  then  took 
place,  and  ulceration  extended  through  the  diaphragm.  Here,  also, 
adhesions  between  the  pleural  surface  of  the  lower  lobe  of  the  left 
lung  and  that  of  the  diaphragm,  prevented  acute  pleurisy  being  at 
once  produced  ;  the  lung  tissue  was  perforated,  and  a  slough  cavity 
was  formed.  The  pleura  subsequently  became  acutely  diseased,  and 
effusion  of  pus  took  place  in  the  non-adherent  part  of  the  serous 
membrane.  The  gangrene  of  the  lung  and  the  ernpyema  led  to  the 
excessive  prostration  in  this  case.  A  second  ulcer  was  found  in  the 
stomach. 

Chronic  Ulceration  with  Hemorrhage. 

CASE  LVI.  Chronic  Ulceration  of  the  Stomach.  Fatal  Hemorrliage. 
Perforation  of  the  Splenic  and  of  the  Pancreatic  Arteries — Charlotte  T — , 
a3t.  55,  was  admitted  into  Guy's  Hospital,  March  4th,  1857,  and  died  March 
5th,  at  9.40  P.  M. 

She  had  previously  been  admitted  under  Dr.  Oldham's  care,  in  a  very 
blanched  condition,  complaining  of  severe  pain  in  the  left  side ;  she  had  had 
no  vomiting  nor  spitting  of  blood,  and  her  appetite  had  failed ;  whilst  in  the 
hospital,  however,  she  took  food  well.  She  was  in  a  week's  time  transferred 
to  Dr.  Wilks's  care,  and  was  then  evidently  suffering  from  internal  hemor- 
rhage ;  she  had  great  pain  and  uneasiness  in  the  left  side,  with  nausea,  but 
did  not  vomit.  During  the  night  she  vomited  a  cupful  of  blood,  and  shortly 
afterwards  died.  She  had  been  a  char-woman  and  of  intemperate  habits, 
and  six  years  before  death  she  had  vomited  blood. 


ORGANIC    DISEASES    OF    THE    STOMACH.  167 

On  inspection,  the  pleura  was  found  adherent,  and  the  lungs  healthy.  The 
left  ventricle  was  contracted  and  empty,  as  in  death  from  loss  of  blood. 

In  the  abdomen  the  peritoneum  was  healthy,  except  adhesion  at  the  upper 
part,  where  the  anterior  wall  was  firmly  united  to  the  stomach  and  liver. 
These  structures  could  be  separated  with  care,  except  at  the  left  hypochon- 
driac region,  where  the  adhesions  were  exceedingly  firm.  The  whole  of  the 
liver,  stomach  and  spleen,  were  removed  together ;  the  stomach  was  found  to 
be  contracted  at  its  centre  by  a  large  oval  ulcer  placed  transversely ;  two 
pouches  were  formed,  the  pyloric  being  the  smaller  of  the  two,  and  the 
cardiac  one  formed  a  large  cavity,  capable  of  holding  at  least  a  quart  of  fluid  ; 
each  part  contained  a  large  quantity  of  coagulated  blood,  partly  digested.  At 
the  posterior  part  of  the  stomach,  near  the  lesser  curvature,  was  a  large  chronic 
ulcer,  with  raised  dense  round  edges,  and  with  a  depressed  slightly  granular 
centre  ;  the  ulcer  was  oval  or  rather  reniform  in  shape,  and  appeared  to  be 
formed  by  two  ulcers  which  had  coalesced  ;  it  was  at  least  three  inches  in 
length,  and  one  and  a  half  to  three  in  breadth.  Its  floor  was  formed  partly 
by  the  left  lobe  of  the  liver,  to  which  it  was  firmly  adherent,  and  by  the  pan- 
creas. Two  small  papilliform  eminences  were  found  on  careful  examination, 
and  a  bristle  could  easily  be  passed  into  open  vessels  ;  one  opening  was  found 
to  communicate  directly  wkh  the  splenic  artery,  on  the  upper  margin  of  the 
pancreas,  and  a  second  with  the  artery  in  the  centre  of  the  pancreas.  Each 
of  the  perforations  in  these  vessels  had  a  small  quantity  of  blood  at  their  orifices, 
but  did  not  contain  any  clot  or  blood.  The  pylorus  and  the  rest  of  the  stom- 
ach were  healthy.  The  intestines  contained  a  considerable  quantity  of  blood, 
but  were  otherwise  healthy.  The  portion  of  the  left  lobe  of  the  liver  in 
connection  with  the  stomach  was  atrophied,  and  it  presented  fibroid  degenera- 
tion ;  the  other  part  of  the  liver  was  fatty.  The  kidneys  were  granular. 

This  case  presents  us  with  an  unusual  mode  of  termination  of  gas- 
tric ulcer.  The  ulceration  had  been  slow  in  its  progress,  and  it  had 
apparently  extended  over  at  least  six  years  or  more ;  there  had  been 
some  hemorrhage,  which  had  probably  come  from  some  of  the 
branches  of  the  gastric  arteries;  as  the  ulceration  extended,  the 
walls  of  the  stomach  were  perforated,  but  adhesions  prevented  peri- 
tonitis. In  this  state  the  health  had  become  impaired  by  disease  of 
the  kidneys,  which  were  found  after  death  in  a  state  of  advanced 
degeneration  ;  slow  ulceration  had  reached  the  vessels  at  the  base  of 
the  ulcer,  and  the  perforation  of  two  large  vessels  led  to  the  fatal 
hemorrhage.  These  vessels  were  healthy,  but  the  ulceration  had  de- 
stroyed the  surrounding  structures  more  extensively  than  the  arteries, 
and  the  contraction  of  the  vessels  was  also  prevented  by  fibro-elastic 
tissue,  so  that  minute  papillary  eminences  were  formed;  the  disease 
of  the  kidneys  and  the  condition  of  the  blood  also  tended  to  increase 
the  hemorrhage.  It  is  remarkable  that  so  little  blood  was  vomited, 
although  the  stomach  was  full,  and  the  intestines  contained  a  con- 
siderable quantity.  The  absence  of  this  symptom  arose  partly,  per- 
haps, from  the  adhesions  of  the  stomach  to  the  parietes,  as  well  as 
from  the  prostrate  condition  of  the  patient. 

As  to  the  cause  of  the  complaint,  we  are  led  to  suppose  that  the 
intemperate  habits  of  the  patient  produced  the  disease  of  the  stomach, 
as  well  as  that  of  the  kidneys;  the  one  tended  to  increase  the  other, 
and  at  last  hastened  the  fatal  termination. 


168  ORGANIC    DISEASES    OF    THE    STOMACH. 

CASE  LVII.  Ulceration  of  the  Stomach.  Fatal  hemorrhage Joseph  G — , 

aet.  53,  was  admitted  into  Guy's  February  28th,  and  died  March  Gtli. 

The  patient  was  admitted  after  hgematemesis  had  taken  place  ;  it  came  on 
suddenly,  and  there  were  no  premonitory  symptoms  ;  he  died  on  the  sixth 
day,  completely  blanched. 

On  inspection,  forty  hours  after  death,  a  small  ulcer  about  the  size  of  a 
fourpenny-piece  was  found  at  the  lesser  curvature  of  the  stomach  ;  it  was 
round,  depressed  in  the  centre,  and  the  edges  of  the  mucous  membrane  were 
raised ;  in  its  centre  was  an  opening  from  which  exuded  a  drop  of  blood,  and 
a  probe  could  be  passed  into  a  large  vessel  beneath,  apparently  the  gastric. 
The  stomach  was  of  normal  size,  and  free  from  blood,  but  the  large  intestines 
contained  blood,  as  shown  by  their  dark  color.  A  partial  inspection  only 
was  allowed. 

Numerous  instances  of  hemorrhage  into  the  stomach  recover,  even 
after  extreme  loss;  the  hemorrhage  is  checked  by  the  formation  of 
clots  in  the  divided  vessel.  This  obstruction  of  vessel  was  well 
shown  in  a  case  of  gastric  ulcer,  which  terminated  fatally  from  bron- 
chitis. Large  hemorrhage  from  the  bowels  had  taken  place  several 
months  previously,  and  on  inspection  two  chronic  ulcers  were  ob- 
served towards  the  anterior  surface  at  the  lesser  curvature,  and  on 
one  of  them  the  truncated  extremity  of  a  small  vessel  was  filled  by 
a  clot. 

A  most  interesting  and  rare  case  of  recovery  after  apparent  per- 
foration is  recorded  by  Dr.  Hughes  and  Mr.  Hilton,  in  the  Guy's 
'  Reports.'  The  young  woman  left  the  hospital,  and  appeared  con- 
valescent; subsequent  indiscretion  in  diet  produced  a  return  of  the 
symptoms,  and  a  fatal  result.  A  cicatrix  of  previous  ulcer  and 
adhesions  were  found,  but  with  new  perforation.  The  opiate  plan 
of  treatment  of  Drs.  Stokes  and  Graves  was  adopted  with  unusual 
success. 

CASE  LVIII.  Chronic  Ulceration,  with  Villous  Growth.  Stomach  ex- 
ceedingly contracted,  simulating  cancer — Thomas  F — ,  set.  34  years,  a  mar- 
ried man,  who  resided  at  Dover,  and  followed  the  occupation  of  a  fruiterer, 
was  admitted  into  Guy's  June  30,  1854,  under  my  care,  in  the  Clincal  Ward, 
in  a  pale  and  exceedingly  emaciated  condition.  With  the  exception  of  an 
attack  of  rheumatism  fifteen  years  before,  his  health  had  been  good  till  eight 
months  prior  to  admission.  He  stated  that  eight  months  previously  he  took 
cold,  and  experienced  pain  in  the  chest,  at  the  lower  part  of  the  sternum, 
accompanied  with  difficulty  of  deglutition.  He  obtained  no  relief,  but  the 
pain  gradually  increased  in  severity,  and  was  accompanied  with  vomiting 
after  food;  his  food  was  brought  up  directly  after  being  swallowed,  his  own 
description  being  that  it  never  seemed  to  reach  the  stomach,  but  was  brought 
up  unchanged  ;  the  vomiting  sometimes  subsided  for  several  days,  and  he 
was  thus  able  occasionally  to  retain  fluid  food  ;  when  this  occurred  he  experi- 
enced relief  from  the  sense  of  painful  exhaustion.  Emaciation  had  slowly 
increased.  On  admission,  his  exhaustion  appeared  extreme,  but  still  he  ex- 
perienced no  pain  ;  the  abdomen  was  collapsed  ;  no  tumor  could  be  felt  ;  the 
distress  on  swallowing  was  localized  at  the  lower  part  of  the  sternum.  At 
the  base  of  the  right  lung  there  was  dulness  on  percussion,  and  some  tubular 
breathing,  but  no  cough  nor  dyspnoea.  He  sank  on  the  fourth  day. 

Inspection. — The  lower  lobe  of  the  right  lung  was  consolidated,  granular, 
and  very  readily  broke  down.  The  heart  was  healthy.  The  peritoneum 


ORGANIC    DISEASES    OF    THE    STOMACH. 


169 


also  was  healthy.  The  stomach  was  so  small  and  concealed  that  it  was  not 
at  first  perceived ;  it  was  exceedingly  contracted  and  lobulated  externally, 
resembling  a  portion  of  large  intestine  ;  it  was  about  six  inches  in  length  and 
two  in  breadth.  On  laying  it  open,  from  the  oesophageal  to  the  pyloric°orifice, 
it  presented  a  very  unusual  appearance.  At  the  pylorus,  and  extending 
along  the  greater  curvature,  was  a  deep  excavation,  or  ulcer,  bounded  by  a 
sharp,  slightly  ulcerated  border,  the  surface  of  which  was  smooth,  and  of  a 
grayish  color.  This  ulcerated  surface  extended  about  half  an  inch  beyond 


Stomach  exceedingly  contracted  from  chronic  ulceration,  with  villous  growth,  simulating  cancer. 
1.  External  view,  resembling  the  colon  in  appearance.  2.  Internal  surface,  showing  ulceration  near 
the  pylorus,  and  villous  growth  uear  the  centre  of  the  stomach. 

the  pylorus ;  passing  towards  the  cardiac  extremity  and  along  the  lesser  cur- 
vature, the  mucous  membrane  appeared  smooth,  shining,  and  glazed  ;  and 
towards  the  cardiac  extremity  presented  several  raised,  circular  patches ;  the 
largest  of  these,  very  near  to  the  ulcer,  was  about  one-eighth  of  an  inch  in 
elevation,  and  about  one  inch  in  diameter,  and  was  composed  of  villous  folds, 
which  appeared  to  radiate  from  the  centre  ;  floated  under  water,  this  growth 
from  the  mucous  membrane  had  a  very  beautiful  appearance  ;  nearer  to  the 
oesophagus  was  another  circular  patch  of  a  similar  description  ;  and  on  either 
side  there  were  slight  folds,  but  less  elevated,  and  having  a  longitudinal  ar- 
rangement. On  taking  a  small  portion  of  this  villous  growth  it  was  found 
to  consist  of  very  delicate  plicated  folds ;  scarcely  any  epithelium  was  found 


170  ORGANIC    DISEASES    OF    THE    STOMACH. 

on  the  surface,  but  numerous  crystals,  resembling  triple  phosphates,  were 
observed  upon  it ;  the  growth  was  composed  of  cells  of  large  size,  from  ^^^t\i 
to  TjjVff*'1  °f  an  incn  in  s'ze>  many  oval,  some  angular;  they  contained  gran- 
ules,  and  large  nuclei  from  the  j0V,Tth  to  g^^th  of  an  inch.  These  cells 
were  very  similar  to  those  found  on  the  mucous  membrane  of  a  healthy 
stomach,  or  in  connection  with  the  gastric  follicles.  A  section  of  the  growth 
rendered  this  more  probable  ;  immediately  beneath  the  surface  of  the  mucous 
membrane  was  a  thick  layer  of  these  secreting  cells,  reaching  to  the  distended 
gastric  follicles,  which  were  tabulated  and  much  distended  by  similar  cells  ; 
beyond  these  enormously  enlarged  gastric  follicles  was  a  stratum  of  white 
fibrous  tissue,  from  one-sixteenth  to  one-eighth  of  an  inch  in  thickness  ;  and 
similar  tissue  extended  between  the  follicles  themselves.  All  the  growths 
from  the  membrane  had  a  like  structure.  On  the  surface  of  the  apparently 
smooth  portion  were  several  small  isolated  dendritic  or  imperfect  villi,  con- 
taining cells,  as  before  described.  Beneath  the  mucous  membrane  was  a 
dense  fibrous  layer,  and  then  hypertrophied  muscular  fibre.  The  hypertrophy 
of  the  muscular  fibre  was  more  marked  towards  the  pylorus,  but  even  there 
did  not  exist  in  an  extreme  degree.  The  examination  of  the  ulcerated  sur- 
face did  not  show  any  structure  which  indicated  the  disease  to  be  of  carci- 
nomatous  character.  The  liver,  pancreas,  and  the  remaining  abdominal 
viscera  and  glands,  were  healthy.  One  kidney  was  large  and  healthy  ;  the 
other  appeared  atrophied. 

The  pathology  of  the  case  just  detailed  is  of  great  interest;  it  could 
not  be  ascertained,  from  minute  inquiries  from  the  patient,  that  he 
had  taken  any  poisonous  or  corrosive  substance.  There  had  appa- 
rently been  inflammation  of  the  mucous  and  submucous  tissues, 
leading  to  very  slow  ulceration  in  one  part ;  in  another,  to  the  de- 
velopment of  contractile  tissue  in  the  substance  of  the  membrane, 
and  producing  contraction  of  the  whole  organ.  The  villous  growths 
at  first  gave  the  idea  of  epithelial  cancer;  but  the  presence  of  gland 
follicles  in  their  normal  arrangement,  though  much  hypertrophied, 
and  the  absence  of  every  other  indication  of  cancer,  led  me  to  the 
belief  that  these  parts  were  merely  portions  of  changed  or  hypertro- 
phied mucous  membrane.  There  was  no  glandular  enlargement  nor 
disease  resembling  carcinoma  in  any  part  of  the  body.  The  disease 
during  life  was  believed  to  be  earcinomatous,  and  located  at  the 
cardiac  extremity  of  the  stomach;  the  manner  in  which  the  food  was 
at  once  regurgitated  or  rejected  from  the  stomach,  the  unrelieved 
pain,  and  steady  emaciation,  seemed  to  warrant  such  a  supposition. 
The  acute  disease  at  the  base  of  the  right  lung  was  interesting,  as 
illustrating  the  manner  in  which  such  disease  in  an  exhausted  subject 
may  take  place  without  general  symptoms.  There  was  neither 
cough,  dyspnoea,  nor  febrile  symptoms;  the  pulse  was  quiet,  and  the 
tongue  clean ;  still,  there  were  dulness  and  tubular  breathing  at  that 
part,  and  the  lung  was  found,  on  inspection,  in  the  second  stage  of 
pneumonia. 

CASE  LIX — The  thickening  producer!  by  hypertrophied  tissues  in  chronic 
ulcer  may  be  so  great  as  to  resemble  cancerous  growths,  as  in  a  case  under 
the  care  of  Sir  W.  Gull,  in  Guy's,  in  I860.  Caroline  D— ,  set.  39.  Four 
months  before  her  death  she  had  rigors  after  dinner,  and  two  months  later  she 


ORGANIC    DISEASES    OP    THE    STOMACH.  171 

began  to  vomit  ;  for  six  weeks  she  had  a  burning  sensation  in  the  throat  and 
oesophagus,  and  for  five  weeks  vomited  everything.  The  urine  contained 
albumen,  the  conjunctiva  was  yellowish  in  color,  and  a  movable  tumor  could 
be  felt.  The  peritoneum  was  studded  with  small,  round,  wart-like  patches, 
witli  black  spots  as  after  minute  hemorrhage.  The  stomach  contained  about  a 
pint  of  dark-colored  fluid,  the  cardiac  end  was  distended  and  its  walls  rather 
thinner  than  usual.  At  the  pyloric  third  of  the  stomach  was  .a  tumor  about 
two  and  a  half  inches  in  transverse,  two  inches  in  vertical,  and  one  and  a 
half  inches  in  antero-posterior  measurement ;  on  section  two-fifths  of  it  were 
hypertrophied  muscle  ;  the  fatty  tissues  were  much  thickened  and  indurated. 
The  thickened  tissues  constituted  the  bulk  of  the  tumor.  There  were  no 
enlarged  glands,  but  an  ulcer  was  situated  two  inches  from  the  opening  of 
the  oesophagus.  The  rest  of  the  stomach  Avas  healthy. 

Cancerous  disease  may,  however,  exist  with  ulcer.  In  a  woman,  aet.  30, 
who  died  from  cancerous  disease  of  the  peritoneum,  which  led  to  complete 
obstruction,  there  was  an  old  callus  ulcer  which  had  destroyed  all  the  coats 
of  the  stomach  ;  the  stomach  was  small  and  as  hard  as  gristle ;  its  walls  in 
the  pyloric  three-fourths  were  three-quarters  of  an  inch  in  thickness,  at  the 
cardiac  position  one-fourth  to  one-sixth.  The  lesser  curvature  was  the 
thickest  part,  at  the  ulcer  the  coats  were  more  than  an  inch  in  thickness. 
There  was  no  milky  juice.  The  gastric  follicles  were  much  wasted. 

Causes. — There  is  much  obscurity  as  to  the  predisposing  cause  of 
ulceration  of  the  stomach.  Some  cases  are  preceded  by  a  state  of 
chronic  inflammation  of  the  whole  mucous  membrane,  produced  by 
intemperance  or  irregularity  in  diet.  In  others  it  appears  probable 
that  the  general  state  of  nutrition  and  of  the  nervous  system  act  as 
predisposing  causes.  Mental  depression  or  anxiety,  scanty  food,  late 
hours  at  night,  and  insufficient  exercise,  pressure  upon  the  scro- 
biculus  cordis,  either  by  direct  girthing  of  the  abdomen,  or  by  con- 
stant and  constrained  position,  as  in  milliners  and  shoemakers,  or  the 
striking  of  the  epigastrium  by  the  shuttle  of  the  weaver,  are  also 
causes  of  gastric  ulcer. 

Treatment. — There  are  several  objects  to  be  sought  for  in  the  treat- 
ment of  ulceration  of  the  stomach : 

1.  The  promotion  of  reparative  action  by  sustaining  and  increasing 
general  nutritive  power. 

2.  The   relief  of  distressing   symptoms,  pain,  vomiting,  hemor- 
rhage, pyrosis,  constipation,  &c. 

3.  The  prevention  of  the  extension  of  the  disease. 

4.  The  removal  of  its  complications. 

1.  Almost  the  first  consideration,  and  certainly  one  of  the  most 
important,  is  the  administration  of  proper  food.  If  absolute  rest 
could  be  afforded  to  the  stomach,  the  ulceration  affecting  its  surface 
would  .probablv  in  many  cases  rapidly  heal ;  but,  since  this  is  almost 
impossible,  it  must  be  our  object  to  give  such  forms  of  nutriment  as 
will  spare  the  stomach ;  and  in  seeking  to  accomplish  this  purpose, 
it  must  be  borne  in  mind  that  the  especial  office  of  the  stomach,  and 
its  peculiar  secretion,  is  the  solution  of  nitrogenous  compounds. 
These  elements  are  found  in  the  flesh  of  animals,  in  beef  and  mutton, 
&c.,  hence  we  generally  find  that  solid  animal  food  produces  pain 


172  ORGANIC    DISEASES    OF    THE    STOMACH. 

and  vomiting,  and  must  in  most  cases  be  avoided.1  If,  however, 
these  elements  of  food  be  given,  they  must  be  in  an  uuirritating 
form,  as  the  less  oleaginous  kinds  of  fish,  the  sole,  whiting,  cod,  &c., 
or  poultry ;  or  in  a  fluid  sta^e,  as  veal  and  mutton  broth,  clear  soups, 
&c. ;  beef-tea  often  creates  nausea  and  vomiting.  Still  more  must 
hard  and  indigestible  meats,  preserved  meats,  and  cheese  be  avoided. 
Oysters,  sweetbread,  can  often  be  taken  when  more  irritating  diet 
would  be  rejected. 

Starchy  food  is  converted  into  sugar  by  the  saliva  and  by  the 
secretions  in  the  intestine,  and  in  that  state  is  readily  absorbed ;  but, 
at  the  same,  it  readily  undergoes  fermentative  change  and  produces 
flatulence,  so  that  in  pyloric  obstruction  it  is  well  to  abstain  from  it. 
So  also,  oleaginous  substances  are  converted  into  an  emulsion  by  the 
alkalies  in  the  secretions  of  the  mouth  and  intestine,  and  in  the  bile  ; 
so  that  these  forms  of  diet,  whilst  they  are  demulcent  and  soothing 
to  the  diseased  gastric  surface,  do  not  require  the  stomach  in  order 
to  place  them  in  a  state  ready  for  absorption.  Good  stale  bread, 
biscuit,  milk,  starchy  substances — as  arrow-root,  tapioca,  maize,  or 
Indian  corn,  flour,  rice,  &c.,  may  thus'be  given  to  the  patient;  eggs 
often  disagree,  but  may  be  taken  in  the  form  of  light  pudding;  milk, 
also,  when  refused  in  its  simple  character,  may  be  better  tolerated 
by  combination  with  isinglass,  as  in  blanc-mange,  or  with  soda  water 
or  lime  water ;  and  even  cream  and  bacon  are  occasionally  well 
borne. 

Kich  soups,  highly  seasoned  dishes,  peppers,  mustard,  &c.,  are 
better  abstained  from ;  so  also  pastries,  and  food  containing  much 
insoluble  material,  as  salads,  unripe  raw  fruit,  green  vegetables,  &c. 
It  is,  however,  undesirable  altogether  to  abstain  from  vegetables,  for 
we  may  thus  defeat  our  object,  by  inducing  cachexia ;  oranges, 
lemons,  &c.,  may  be  often  taken  with  benefit. 

Again,  it  is  most  important  that  food  should  be  partaken  of  sloAvly, 
and  thoroughly  masticated ;  and  it  is  better  to  take  small  quantities 
at  a  time,  and  to  repeat  the  allowance  more  frequently,  than  to  dis- 
tend the  stomach  by  a  large  and  bulky  meal ;  about  three  to  four 
hours  should  intervene  in  ordinary  cases,  but  when  there  is  great 
exhaustion,  with  irritability  of  the  stomach,  food  may  be  required 
more  frequently,  and  in  very  small  quantities.  Exertion,  both 
mental  and  physical,  should  be  avoided  directly  after  meals ;  in  fact, 
everything  should  be  done  to  facilitate  the  process  of  digestion.  It 
is  well  to  abstain  from  alcoholic  liquors  if  possible ;  they  tend  to 
aggravate  the  disease,  and  should  not,  I  think,  be  given  unless  the 
circulation  be  failing,  and  there  be  tendency  to  syncope ;  but,  when 
required,  brandy  in  small  quantity  and  well  diluted,  or  the  forms  ot 
sherry  which  contain  the  least  quantity  of  sugar  are  best.  New 
wines,  port,  and  imperfectly  fermented  malt  liquors,  generally  dis- 
turb and  distress  the  patient. 

It  is  desirable  to  use  every  means  in  our  power  to  improve  the 

1  Corvisart  has  shown  that  the  pancreatic  fluid  promotes  the  solution  ot  nitroge- 
nous substances. 


ORGANIC    DISEASES    OF    THE    STOMACH.  173 

health,  as  exercise  in  the  open  air;  but  over-fatigue,  or  constrained 
positions,  should  be  avoided.  Moderate  horse  exercise,  and  bracing 
air,  will  sometimes  afford  more  relief  than  medicinal  agents,  even 
when  long  continued ;  but  violent  shaking  is  injurious.0  When  a 
chlorotic  or  anaemic  state  has  been  produced,  the  preparations  of 
steel,  by  restoring  a  more  healthy  condition  of  the  blood,  greatly 
facilitate  reparative  changes.  We  prefer  the  milder  preparations,  as 
the  ammonio-tartrate  or  citrate ;  the  compound  steel  pill,  with  aloes 
and  myrrh,  or  quinine  with  iron,  as  the  sulphate  or  citrate  conjoined, 
majr  also  be  beneficially  prescribed. 

It  is  obviously  most  desirable  to  administer  that  form  of  aliment 
which  will  nourish  the  body,  so  that  healing  may  be  favored,  but 
without  irritating  and  disturbing  the  process  which  is  going  on 
towards  recovery.  The  difficulty  is  still  more  increased  by  the  occa- 
sional irritability  of  the  stomach  itself;  and  this  leads  us  to  the  con- 
sideration of  the  means  we  possess  for  the  mitigation  of  distressing 
symptoms — pain,  vomiting,  hemorrhage,  pyrosis,  constipation.  For 
the  relief  of  pain,  opium  or  its  alkaloid  morphia  is  often  the  best 
remedy,  in  doses  of  |  to  1  grain  of  the  former  two  or  three  times  a 
day,  or  a  few  minims  of  the  solution  of  the  latter.  Chloric  ether, 
in  doses  of  10,  15,  to  20  minims,  will  be  found  very  efficacious,  espe- 
cially when  combined  with  nitrate  of  bismuth  in  10-  to  20-grain 
doses.  Chlorodyne  is  stated  as  being  a  valuable  substitute,  but  I 
have  no  experience  in  its  use.  Dilute  hydrocyanic  acid,  in  doses  of 
3  to  5 HI,  is  also  a  useful  adjunct  in  some  cases,  especially  when  given 
with  alkalies.  Both  potash,  soda,  lime,  and  magnesia,  have  been 
used  ;  they  neutralize  acid  secretion,  and  oftentimes  increase  the  ano- 
dyne power  of  the  remedies  previously  mentioned — opium,  morphia, 
chloric  ether,  &c.  If,  however,  there  be  constipation,  dryness  of  the 
tongue,  and  opium  is  not  well  borne,  conium  or  henbane  may  be 
used  as  substitutes.  The  nitrate  arid  oxide  of  silver,  in  doses  of  ^ 
to  1  grain,  in  some  instances  diminish  the  pain  and  irritability  of  the 
stomach,  especially  when  the  gastric  symptoms  are  associated  with 
pyrosis.  Creasote  or  carbolic  acid  in  l^l  doses  we  have  found  very 
effectual  in  relieving  pain,  when  accompanied  with  irritability  of  the 
stomach,  or  with  vomiting  and  fermentative  changes  in  the  food. 
Charcoal  is  also  a  remedy  which  in  some  cases  acts  very  speedily 
and  efficaciously  in  relieving  pain  and  flatulent  distension.  Again, 
carbonic  acid,  as  in  ordinary  soda  water,  is  effective  in  relieving  pain 
as  well  as  vomiting.  So  also  the  use  of  cold  water  and  ice,  which 
are  often  very  grateful  to  the  patient. 

Vomiting  is  a  very  distressing  symptom  in  many  cases  of  ulcer  of 
the  stomach.  It  is  best  combated  by  only  partaking  of  fluid  diet, 
and  of  that  in  moderate  quantities.  The  remedies  we  have  already 
mentioned  are  of  service,  but  especially  bismuth,  hydrocyanic  acid, 
creasote,  ice,  and  the  alkalies. 

Sir  Wm.  Jenner  has  pointed  out  the  value  of  the  sulphite  of  soda 
in  checking  the  fermentative  action,  and  the  development  of  sarcinae 
in  obstruction  from  chronic  ulcer,  as  well  as  in  cancerous  and  pyloric 


174  ORGANIC    DISEASES    OF    THE    STOMACH. 

disease.  It  may  be  given  in  ^j  doses,  alone  or  conjoined  with  other 
agents;  the  hyposulphite  is  also  given  in  similar  cases. 

Counter-irritants  are  often  of  service  for  the  relief  of  pain  and 
vomiting  in  these  cases.  A  small  blister,  may  be  applied  to  the  scro- 
biculus  cordis,  or  croton  oil  rubbed  in  so  as  to  produce  a  pustular 
eruption.  Some  even  use  a  seton ;  but  I  think,  that  we  may  attain 
the  same  beneficial  result  by  milder  remedies  with  less  suffering  and 
distress  to  the  patient. 

If  there  be  excessive  secretion  or  hemorrhage,  astringents  may  be 
given;  thus,  mineral  acids,  as  the  sulphuric  alone,  or  with  Epsom 
salts;  acetate  of  lead,  tannin,  and  alum,  are  also  available;  and 
when  we  have  hemorrhage  without  great  irritability,  small  doses  of 
turpentine  with  mucilage  or  yolk  of  egg  may  be  prescribed.  Tinc- 
ture of  iron  is  sometimes  very  effective  in  checking  the  hemorrhage. 

When  hemorrhage  has  recently  taken  place,  it  is  well  to  avoid 
the  use  of  anything  likely  to  distend  or  mechanically  to  disturb  the 
stomach,  as  carbonic  acid.  Ice,  however,  should  be  allowed  to  the 
patient,  as  it  tends  to  produce  contraction  of  bleeding  vessels. 

Pyrosis  may  be  checked  by  the  astringents  just  mentioned ;  but 
we  have  found  the  greatest  benefit  from  nitrate  or  oxide  of  silver 
with  opium,  from  creasote  or  carbolic  acid,  from  the  compound  kino 
powder,  and  when  other  symptoms  would  permit  it,  from  the  astrin- 
gent preparations  of  iron. 

The  bowels  should  be  acted  upon  by  agents  which  are  neither 
retained  in  the  stomach,  nor  irritating  to  it,  as  the  aloes  or  colocynth 
pill,  with  henbane;  the  effervescing  citrate,  the  carbonate  or  Dinne- 
ford's  fluid  magnesia ;  in  other  instances  enemata  are  useful,  consisting 
of  simple  water  or  castor  oil,  or  of  turpentine;  and  occasionally  a 
mercurial  purgative  will  be  found  beneficial  in  thoroughly  emptying 
the  canal  without  increasing  gastric  irritability,  as  a  few  grains  of 
gray  powder,  one  or  two  of  calomel,  or  of  blue  pill,  with  henbane, 
&c. ;  but  to  continue  this  form  of  medicine  is,  we  think,  injurious 
and  prejudicial  to  the  patient.  In  many  cases  of  constipation  with 
gastric  disease,  minute  doses  of  strychnia,  or  of  the  extract  of  nux 
vomica  with  aloes,  act  very  beneficially. 

In  order  to  carry  out  the  third  indication  of  treatment,  namely, 
in  preventing  the  extension  of  the  disease,  sudden  and  violent  exertion 
should  be  guarded  against;  and  also  the  distension  of  the  stomach  by 
large  meals,  or  by  food  which  leads  to  the  formation  of  gaseous  pro- 
ducts, as  the  result  of  fermentative  changes. 

4th.  In  the  treatment  of  the  complications  of  gastric  ulcer,  arising 
from  its  extension  to  neighboring  parts,  as  when  perforation  has  taken 
place,  and  the  symptoms  of  peritonitis  have  been  suddenly  produced, 
there  is  still  a  slight  chance  that  life  may  be  prolonged,  if  the  patient 
is  not  moved,  nor  anything  introduced  into  the  stomach,  except  a 
teaspoonful  of  water  or  milk  to  assuage  thirst.  Opium  must  be 
given  freely,  as  recommended  by  Dr.  Stokes  and  Dr.  Graves,  so  that 
the  patient  may  be  entirely  under  its  influence — a  grain  every  three 
or  four  hours — by  this  means  peristaltic  action  is  checked,  nervous 
shock  diminished,  extravasation  prevented,  adhesions  promoted,  and 


ORGANIC    DISEASES    OF    THE    STOMACH.  175 

life  may  be  thus  preserved.  For  many  days  aperient  remedies  should 
be  avoided,  and  food  only  taken  in  the  most  cautious  manner. 

If  local  suppuration  have  taken  place,  opium  is  still  the  best  remedy, 
in  order  to  diminish  irritative  fever,  to  relieve  pain,  and  to  place  the 
patient  in  the  most  favorable  condition  for  reparative  action.  If  the 
disease  have  extended  into  the  chest,  the  prospects  of  recovery  are 
still  less ;  for  sudden  acute  pleurisy  and  empyema,  or  asthetic  pneu- 
monia are  almost  certain  to  follow.  Life  may  be  prolonged  by 
sustaining  the  patient,  and  the  severity  of  the  symptoms  of  acute 
disease  of  the  chest  may  be  partially  relieved  by  ammonia  and  opium. 

The  two  following  cases  illustrate  the  relief  that  may  be  afforded 
by  the  treatment  just  recommended. 

CASE  LX.  Chronic  Ulcer  of  the  Stomach.  Relieved Jane  H — ,  art.  34, 

was  admitted  under  my  care  into  Guy's  Hospital,  May  1,  1861.  She  was  a 
married  woman,  but  had  had  no  family.  For  eleven  years  she  had  had  pain 
at  the  stomach,  with  frequent  attacks  of  vomiting  of  clear  fluid.  In  1858 
she  vomited  a  large  quantity  of  blood,  and  eighteen  months  later  had  a 
second  attack  of  haematemesis.  During  three  months  prior  to  admission, 
she  had  continued  pain  at  the  scrobiculus  cordis,  extending  to  the  spine,  and 
increased  by  food  ;  there  was  tenderness  at  the  scrobiculus  cordis ;  and  she 
became  so  weak  as  to  be  obliged  to  keep  her  bed.  For  two  months  she  had 
had  vomiting,  sometimes  directly  after  food,  at  other  times  an  hour  after- 
wards ;  the  bowels  were  constipated.  On  admission  she  was  emaciated,  and 
rather  sallow  ;  there  was  tenderness  and  increased  pulsation  at  the  scrobiculus 
cordis.  She  was  most  free  from  pain  when  lying  partly  on  the  back  and 
towards  the  left  side.  The  pulse  was  very  compressible,  74 ;  the  tongue  was 
very  red  in  the  centre;  the  respiration  was  coarse  at  the' apices  of  both 
lungs  ;  menstruation  was  scanty  and  irregular,  and  had  disappeared  for  two 
months.  She  was  ordered  colocynth  pill,  with  henbane  at  night ;  and  nitrate 
of  bismuth  with  chloric  ether  three  times  a  day,  and  food  in  a  fluid  form. 

8th Symptoms  relieved  ;  no  vomiting,  and  less  pain.  She  continued  to 

improve  greatly,  and  left  the  hospital  convalescent  on  May  27th. 

There  appeared  to  be  little  doubt,  in  this  instance,  as  to  the 
presence  of  an  ulcer  in  the  stomach ;  and  we  have  very  rarely  ob- 
served a  greater  measure  of  relief  than  she  experienced. 

CASE  LXI.  Ulceration  (cancerous1?)  of  the  Stomach.  Relieved. — David 
H — ,  aet.  36,  was  admitted  into  Guy's  Hospital  under  my  care,  April  8,  1861. 
He  was  a  married  man,  a  printer,  who  had  resided  at  St.  Luke's.  Fifteen 
months  previously  he  had  drunk  gin  immoderately,  and  violent  vomiting  was 
produced  ;  no  blood,  however,  was  ejected.  After  that  time  he  had  suffered 
from  pain  across  the  abdomen  and  in  the  back.  The  pain  was  greatly 
increased  by  food,  and  vomiting  came  on  directly  after  it  had  been  taken  ; 
but  for  six  weeks  the  pain  had  been  less  severe.  His  diet  had  consisted  of 
beef  tea,  eggs,  milk,  etc.  He  was  greatly  emaciated,  sallow,  and  had  an 
anxious  expression  of  countenance.  A  hard  tumor,  about  two  inches  across, 
could  be  felt  at  the  scrobiculus  cordis.  The  action  of  the  heart  was  feeble, 
and  the  pulse  was  very  compressible.  Extract  of  nux  vomica,  with  disul- 
phate  of  quinine  and  aloes,  and  myrrh,  were  given  three  times  a  day. 

April  18th He  complained  of  intense  pain  at  the  scrobiculus  cordis, 

unrelieved  by  position,  and  increased  by  food.  There  were  spots  of  purpura 
on  the  legs.  He  craved  for  meat,  but  refused  vegetables.  Soap  and  opium 


176  ORGANIC    DISEASES    OF    THE    STOMACH. 

pill  were  prescribed  night  and  morning;  and  lemon  juice,  with  infusion  of 
calumba,  three  times  a  day. 

20th — Although  he  had  no  vomiting,  the  pain  was  very  severe  at  the 
stomach  ;  he  was  more  prostrate  and  distressed,  the  bowels  were  constipated, 
and  he  was  unable  to  take  solid  food.  The  opium  was  continued,  and  he 
was  directed  to  take  chloric  ether  with  bismuth. 

22d — He  was  very  much  relieved. 

30th — Again  suffered  severe  pain.  He  was  in  the  habit  of  taking  a  small 
quantity  of  food,  and  after  a  short  time,  because  the  pain  became  very  severe, 
he  endeavored  to  excite  vomiting,  as  affording  the  only  means  of  relief.  He 
was  very  much  emaciated  and  prostrate  ;  but  he  said  that  he  was  rather  easier 
when  sitting  up.  Opium  was  added  to  his  medicine. 

May  28th. — Very  prostrate,  and  emaciated  to  an  extreme  degree ;  but  he 
said  that  he  was  well,  because  the  pain  and  vomiting  had  subsided.  The 
tumor  at  the  scrobiculus  cordis  was  less  distinct. 

June  8th — The  gastric  symptoms  continued  in  abeyance,  and  he  left  the 
hospital  in  improved  health. 

The  pain  produced  by  the  reception  of  food  into  the  stomach,  and 
increasing  till  vomiting  had  taken  place,  was  very  characteristic  of 
organic  gastric  disease.  The  prostration  was  excessive ;  but  when 
almost  pulseless,  and  when  the  pain  and  vomiting  had  subsided,  the 
patient  stated  that  he  was  well,  and  he  insisted  on  endeavoring  to 
walk  about.  It  was  a  good  illustration  of  the  benefit  of  avoiding 
fresh  causes  of  irritation,  and  opium  with  chloric  ether  afforded 
great  relief;  but  although  he  left  the  hospital  free  from  pain,  we 
fear  the  disease  was  advancing,  and  would  lead  to  a  fatal  result. 

Sloughing  of  the  Mucous  Membrane  of  the  Stomach. — The  action  of 
caustic  poisons  is  the  ordinary  cause  of  sloughing  of  the  mucous 
membrane  of  the  stomach ;  but  in  the  two  following  cases  the  ap- 
pearance was  peculiar,  and  very  different  from  that  produced  by  a 
clot  of  blood  covering  an  ulcer.  At  the  lesser  curvature  of  the 
stomach  there  were  several  black  patches,  the  largest  being  about 
an  inch  in  length ;  and  other  smaller  patches  were  placed  in  the 
same  direction  along  the  lesser  curvature.  The  black  central  por- 
tion could  not  be  removed  from  the  tissue  beneath ;  but,  on  section, 
it  was  found  that  a  cup  had  been  formed  of  fibrous  tissue  surround- 
ing the  base  and  on  either  side  of  the  slough,  showing  either  that  an 
inflammatory  condition  had  preceded  the  loss  of  vitality  in  this  iso- 
lated portion  of  membrane,  or  that  having  sloughed,  this  new  action 
had  been  set  up  around  it.  The  appearance  presented  was  very 
similar  to  an  ordinary  bed-sore  on  the  sacrum.  A  slight,  unusual 
irritation,  with  depressed  vital  power,  appeared  sufficient  to  cause 
total  loss  of  vitality.  Effusion  of  blood  into  the  substance  of  the 
mucous  membrane  probably  preceded  this  change,  and  it  closely 
corresponded  with  a  condition  sometimes  found  in  the  lung,  namely 
that  observed  when  hemorrhage  into  the  substance  of  the  lung  is 
followed  by  loss  of  vitality  in  the  part ;  and  one  or  more  lobules  of 
the  lung  are  found  detached  by  an  attempt  at  reparative  action. 

The  cases  here  recorded,  confirm  the  opinion  expressed  by  Dr. 
Copland,  and  are  in  accordance  with  the  experiments  of  others,  that 
the  condition  of  the  nervous  system  has  an  important  influence  on 


ORGANIC    DISEASES    OF    THE    STOMACH.  177 

the  mucous  membrane  of  the  stomach.  In  both  cases  there  was 
acute  pneumonia ;  in  the  one,  with  renal  anasarca,  in  the  other,  with 
paraplegia.  The  effect  of  division  of,  or  disease  implicating  the 
pneumogastrie  nerve,  on  the  nutrition  of  the  lung,  is  shown  by  great 
congestion,  and  often  by  acute  pneumonia,  as  we  have  remarked  in 
the  consideration  of  diseases  of  the  oesophagus ;  instances  also  are 
very  frequent  of  functional  disease  of  the  stomach  arising  from  irri- 
tation of  the  pulmonary  branches,  and  cerebral  centre  of  the  pneu- 
mogastrie nerve ;  bat  the  production  of  organic  change  in  the 
stomach  by  division  or  disease  of  the  nerve  has  not  been  established. 

CASE  LXII.  Ulcer ati on  of  the  Stomach.  Sloughing.  Paraplegia.  Soft- 
ening of  the  Spinal  Cord.  Disease  of  the  Vertebra Elizabeth  G — ,  aet. 

33,  was  admitted  February  23d,  1855.  She  had  been  ill  for  six  weeks  with 
paraplegia.  'Sloughing  of  the  hips,  &c.,  followed,  and  she  gradually  sank. 

Inspection  thirty-six  hours  after  death. — Opposite  the  eleventh  dorsal 
vertebra  the  cord  was  quite  diffluent ;  and  this  softening  extended,  though  in 
rather  less  degree,  to  the  upper  part  of  the  dorsal  region.  It  was  more  marked 
in  the  posterior  column.  Chest — The  bronchi  were  congested,  and  were 
full  of  tenacious  mucus ;  the  lower  lobes  of  the  lungs  were  in  a  state  of  red 
hepatization,  being  red,  fleshy,  and  very  soft.  The  mitral  valve  was  thick- 
ened. Abdomen — Omentum  attached  to  the  bladder ;  the  stomach  was 
placed  vertically,  and  was  distended ;  it  was  pulled  down  lo  the  pelvis,  and 
occupied  half  the  abdomen.  Stomach — Much  enlarged,  containing  grumous 
fluid  ;  its  greater  curvature  presented  post-mortem  solution,  and  the  mucous 
membrane  was  partially  destroyed.  Above  the  line  of  solution  there  were 
several  ulcers  about  the  size  of  a  shilling  piece.  The  mucous  membrane  at 
the  margin  of  the  ulcers  was  pale  and  slightly  raised,  and  the  floor  of  the 
ulcers  was  covered  by  a  black  slough.  The  intestines  were  much  congested. 
The  liver  was  very  fatty.  The  spleen  was  healthy.  The  bladder  was  slough- 
ing, as  also  were  the  vagina  and  os  uteri,  so  that  there  was  free  communica- 
tion between  them.  The  uterus  contained  a  decomposing  foetus  of  about  two 
months. 

CASE  LXIII.  Mottled  Kidney.  Anasarca.  Pneumonia,.  Sloughing 
Mucous  Membrane  of  the  Stomach. — Stephen  F — ,  aet.  51,  was  admitted 
April  10th,  and  died  April  20th,  1855,  from  chest  disease.  Nine  years  before 
he  had  had  scarlet  fever,  and  for  the  last  eighteen  months  he  had  not  been 
well.  On  admission  the  urine  was  very  albuminous. 

Inspection  fourteen  hours  after  death — The  body  was  generally  anasarcous. 
The  lower  lobe  of  the  left  lung  was  red,  consolidated,  and  almost  breaking 
down.  The  rest  of  the  lung  was  very  cedematous.  The  bronchi  were  full  of 
frothy  mucus.  The  left  ventricle  was  much  hypertrophied.  The  weight  of 
the  heart  was  17  oz.  At  the  lesser  curvature  of  the  stomach  were  several 
sloughs ;  the  largest  two  inches  in  length,  and  about  one  in  breadth,  black, 
and  slightly  raised;  a  section  showed  that  the  slough  was  situated  in  a  cup 
of  slightly  thickened  tissue.  Two  smaller  sloughs  were  situated  near  to  it. 
On  microscopical  examination  of  the  adjoining  portions  of  mucous  membrane, 
the  gland  follicles  were  not  distinct ;  and  on  the  surface  were  columnar  epi- 
thelium and  crystals,  &c.  The  small  intestines  were  healthy.  The  spleen 
was  small,  firm,  and  lardaceous.  The  kidneys  were  mottled,  and  the  Mal- 
pighian  bodies  were  degenerated  and  lardaceous. 

An  instance  recently  occurred  in  Guy's  of  acute  tuberculosis  in  a 
young  man,  in  whom  the  lungs  were  filled  with  miliary  tubercle;  in 
12 


178  ORGANIC    DISEASES    OF    THE    STOMACH. 

the  stomach,  at  the  lesser  curvature,  on  both  the  anterior  and  posterior 
walls,  were  several  ulcers  about  a  quarter  of  an  inch  in  diameter, 
with  red  well  defined  margins,  and  containing  at  their  bases  a  dark 
slough.  Excepting  at  the  edges  of  the  ulcers  the  mucous  membrane 
appeared  healthy,  and  there  was  no  evidence  of  chronic  disease. 
There  was  no  obstruction  about  the  coronary  arteries  or  veins.  The 
liver  contained  three  small  hydatid  cysts,  and  there  was  the  remains 
of  one,  a  calcareous  cyst,  at  the  apex  of  the  left  ventricle.  There 
was  strumous  disease  of  the  left  kidney  and  prostate  gland. 

Fibroid  Degeneration  of  the  Pylorus. — The  condition  of  the  pyloric 
valve  in  which  degeneration  of  a  fibroid  character  is  found  to  exist, 
has  been  and  still  is  by  many  pathologists  considered  as  a  form  of 
cancerous  disease,  by  others  as  hypertrophy  of  the  normal  constitu- 
ents of  the  affected  part.  If,  however,  the  diseased  structure  be 
carefully  examined,  no  evidence  of  cancer  will  be  found  in  it,  or  in 
the  adjoining  parts.  The  diseaise  apparently  commences  in  the  sub- 
mucous  cellular  tissue,  which  undergoes  fibrous  thickening,  whilst 
the  mucous  coat  is  in  many  cases  unacted  upon.  This  fibroid  deposit 
leads  to  obstruction  at  the  valve ;  the  muscular  coat  then  becomes 
hypertrophied,  and  the  amount  of  the  hypertrophy  is  an  indication 
of  the  degree  of  obstruction ;  the  disease  may  be  essentially  hyper- 
trophic  in  character  and  due  to  excessive  action  of  the  valve. 

The  growth  beneath  the  mucous  membrane  is  whitish  in  color, 
firm,  and  without  any  juice,  as  in  cancer,  sometimes  cartilaginous  in 
hardness;  it  consists  of  elongated  or  wavy  fibres,  resembling  a  fibroid 
tumor,  which  with  acetic  acid  present  numerous  elongated  nuclei ; 
bands  of  similar  tissue  pass  between  portions  of  involuntary  muscular 
fibre;  and  externally  the  omen  turn  may  be  contracted,  and  adhesions 
may  have  been  formed  with  adjoining  structures. 

The  symptoms  closely  resemble  those  of  cancerous  obstruction; 
and  they  consist  in  chronic  dyspepsia,  followed  by  emaciation,  vomit- 
ing occurring  several  hours  after  food,  pain,  distension  of  the  stom- 
ach, with  eructations,  fermentation,  and  the  development  of  sarcina 
ventriculi,  constipation  and  gradual  exhaustion,  till  at  last  the  patient 
sinks  from  inanition.  The  abdominal  walls  are  wasted  and  collapsed, 
and  a  tumor  is  often  felt  at  the  epigastric  region,  consisting  of  the 
thickened  tissues  at  the  pylorus.  If,  however,  the  stomach  be  free 
from  adhesions,  the  thickened  pylorus  is  often  pushed  downwards, 
so  as  to  be  felt  near  the  umbilicus,  or  even  near  to  the  pubes.  It 
must  not,  however,  be  supposed  that  the  pylorus  can  always  be  felt 
by  tactile  examination ;  sometimes  the  most  careful  manipulation 
fails  to  detect  it,  although  it  may  be  in  a  thickened  condition.  Pain 
is  not  generally  a  marked  symptom  of  this  form  of  pyloric  disease ; 
but  tenderness  on  pressure  is  sometimes  present,  and  this,  perhaps, 
arises  from  peritoneal  adhesions. 

The  distension  of  the  stomach  often  becomes  extreme,  and  the 
movements  of  the  hypertrophied  muscular  fibre  may  be  seen  through 
the  wasted  parietes.  This  peristaltic  movement  may  be  induced  by 
swallowing  a  little  water  or  food ;  but  both  the  distension  and  peris- 


ORGANIC  DISEASES  OF  THE  STOMACH.          179 

talsis  are  less  distinct  when  pyloric  disease  is  acute,  and  may  be 
altogether  absent. 

After  death,  in  some  cases,  we  find  evidence  of  chronic  change, 
and  a  gray  and  .thickened  appearance  of  the  mucous  membrane  of 
the  stomach,  and  a  chronic  ulcer  or  cicatrix  are  occasionally  present. 
At  the  pylorus  the  mucous  membrane  may  be  quite  healthy,  having 
distinct,  or  even  hypertrophied  gastric  follicles ;  but  the  irritation  at 
the  part  may  have  excited  secondary  disease  and  ulceration.  The 
glands  near  the  pancreas  are  not  usually  affected. 

The  diagnosis  is  sometimes  obscure,  and  the  presence  of  other 
more  acute  disease  may  entirely  mask  the  complaint.  The  duration 
of  life  after  fibroid  degeneration  has  taken  place  is  greater  than  in 
.the  ordinary  forms  of  cancer,  especially  medullary  and  epithelial 
cancer;  and  in  simple  fibroid  disease  the  cachexia  has  not  the 
expression  peculiar  to  cancerous  affections ;  but  it  will  be  found 
extremely  difficult  to  distinguish  these  diseases  during  life,  especially 
when  only  observed  at  their  earlier  stages. 

We  are  not  acquainted  with  the  predisposing,  nor  with  the  exciting 
causes  of  this  fibroid  disease ;  but  it  is  probable  that  long-continued 
irritation,  as  indicated  by  dyspepsia,  generally  precedes  it.  The 
intemperate  do  not  appear  to  be  more  liable,  and  one  sex  is  equally 
the  subject  of  it  as  the  other ;  it  occurs,  also,  in  early  and  middle, 
as  well  as  in  advanced  life. 

As  to  treatment,  we  can  afford  relief,  but  cannot  remove  the  ob- 
struction. The  change  from  solid  and  irritating  food  to  fluid  and 
unirritating  nutriment  is  often  followed  by  much  benefit;  and  we 
may  use  with  advantage  those  agents  and  means  which  have  been 
recommended  in  chronic  ulceration  of  the  stomach.  It  is  very  im- 
portant to  administer  fluid  diet  of  a  kind  that  does  not  easily  under- 
go fermentative  change,  as  milk,  meat,  soup,  &c.,  but  if  vegetable 
food  cannot  be  taken,  lemon  juice  should  be  substituted  for  it. 

CASE  LXIV.  Thickened  Pylorus.  Cicatrix  of  the  Mucous  Membrane, 
with  Hypertrophy.  Ulceration  of  the  Caecum  and  Colon.  Fatty  degenera- 
tion of  the  Heart G —  G — ,  a  silk  weaver,  get.  62,  was  admitted  in  a  pros- 
trate and  anaemic  condition.  He  had  had  haemorrhoids  for  twenty  years  ; 
and  he  had  occasionally  lost  a  considerable  quantity  of  blood.  Four  months 
before  admission,  he  had  violent  rain  from  the  hip  to  the  foot,  and  his  legs 
swelled.  Violent  pain  also  came  on  in  the  region  of  the  stomach.  Diarrhoea 
followed,  and  continued  till  death. 

On  inspection,  the  heart  was  found  to  be  fatty,  the  colon  and  caecum  ulce- 
rated. The  stomach  was  somewhat  enlarged,  and  its  mucous  membrane  pale  ; 
at  the  greater  curvature,  for  a  space  of  about  two  inches  in  circumference, 
the  mucous  membrane  was  thickened,  and  was  a  little  puckered  ;  and  at  the 
upper  border  of  this  patch  was  a  small  growth,  consisting  of  thickened  and 
prominent  mucous  membrane,  about  one-eighth  of  an  inch  above  the  remain- 
ing part.  On  examining  the  raised  portion,  it  was  found  to  consist  on  the 
surface  of  columnar  epithelium,  and  beneath  of  cell  structure.  The  nuclei 
of  the  cells  were  very  distinct ;  and  gave  the  idea  of  cancer,  but  they  were 
identical  with  the  secreting  cells  ordinarily  observed  in  a  healthy  organ.  The 
pylorus  was  much  thickened,  and  consisted  of  dense  fibrous  tis  ue,  passing 
between  bundles  of  involuntary  muscular  fibre.  There  were  no  true  cancer- 


180  ORGANIC    DISEASES    OF    THE    STOMACH. 

ous  structures,  and  the  diseased  condition  of  the  pylorus  arose  from  fibroid 
degeneration  of  the  submucous  and  submuscular  tissues,  which  had  been 
followed  by  hypertrophy  of  the  muscular  coat.  See  Drawing,  in  Museum, 
No.  29850,  Prep.  180G73. 

This  fibroid  degeneration,  with  hypertrophy,  contrasted  remark- 
ably with  true  scirrhous  disease,  ft  had  not  led  to  the  ordinary 
symptoms  of  obstructed  pylorus,  and  was  not  diagnosed  during  life; 
the  cause  of  death  was  exhaustion  from  diarrhosa  in  an  anaemic 
subject. 

CASE  LXV.  Diseased  Pylorus.  Phthisis — Mary  W — ,  jet.  22,  admitted 
into  Guy's  Hospital  December,  1856.  She  stated  that  she  had  worked  at  the 
fur  trade,  and  was  nearly  always  in  a  stooping  posture  ;  three  years  previously 
vomiting  had  come  on,  preceded  by  pain  across  the  chest ;  the  symptoms, 
however,  were  much  relieved,  and  she  married ;  in  a  short  time  she  became 
pregnant,,  and  the  symptoms  returned ;  they  were,  however,  regarded  as 
sympathetic  from  the  uterine  condition.  After  her  confinement  she  nursed 
for  seven  months  ;  and  for  four  months  prior  to  admission  she  had  constant 
vomiting,  which  came  on,  several  hours  after  taking  food ;  she  suffered  from 
constipation,  and  gradually  emaciated. 

On  admission  into  Guy's  she  was  exceedingly  wasted,  and  had  a  strumous 
appearance ;  her  complexion  was  dark,  and  she  was  anaemic ;  she  suffered 
from  flatulent  distension,  which  was  easily  dispersed,  and  complained  of 
burning  pain  at  the  stomach  ;  the  vomiting  often  came  on  about  six  o'clock 
in  the  evening ;  on  examination  of  the  abdomen,  a  prominent  tumor  could  be 
felt  at  the  region  of  the  pylorus.  The  vomiting  after  food  and  emaciation 
continued,  and  medicine  afforded  very  temporary  relief;  a  few  weeks  before 
death  cough  came  on  and  expectoration  ;  she  died  March  10th  ;  her  death 
had  been  expected  week  after  week,  but  still  she  lingered  on,  and  at  last  the 
emaciation  became  extreme.  A  short  time  before  admission  she  had  slight 
haemoptysis,  but  there  was  no  evidence  of  disease  of  the  chest  at  that  time. 

Inspection  was  made  on  March  12th.  On  opening  the  abdomen  scarcely 
anything  but  the  enormously  distended  stomach  could  be  seen  ;  the  pylorus 
was  somewhat  depressed,  and  the  greater  curvature  reached  nearly  to  the 
pubes.  The  tumor  consisted  of  the  diseased  pylorus.  The  interior  of  the 
stomach  presented  a  growth  at  the  pylorus  which  completely  surrounded  the 
valve,  so  that  the  little  finger  could  not  pass ;  the  growth  extended  nearly 
two  inches  into  the  stomach  ;  the  disease  was  of  the  character  which  has  been 
described  as  hypertrophy,  and  was  manifested  in  a  very  marked  degree.  The 
semi-transparent  muscular  layer  was  more  than  a  quarter  of  an  inch  in  thick- 
ness, and  was  traversed  by  delicate  lines ;  upon  it  was  placed  a  very  dense, 
whitish  substance,  nearly  half  an  inch  in  thickness,  firm  and  tough  in  texture, 
which  could  be  cut  with  difficulty  ;  on  pressure  no  juice  exuded ;  upon  this, 
again,  was  thickened  mucous  membrane ;  the  surface  was  not  ulcerated,  but 
was  whitish  in  color,  and  irregularly  tuberculated.  The  disease  did  not  ter- 
minate so  abruptly  in  the  duodenum  as  we  often  find,  but  gradually  subsided 
to  the  natural  thickness  of  the  intestine.  The  duodenum  was  otherwise 
healthy ;  so  also  the  mucous  membrane  of  the  rest  of  the  stomach.  The  in- 
testines, liver,  kidney,  and  glands  were  healthy. 

On  microscopical  examination,  the  non-maglignant  character  of  the  growth 
was  well  shown.  The  mucous  membrane  at  the  pylorus  covering  it  was 
thickened,  but  presented  normal  structure  ;  the  gastric  follicles  were  beauti- 
fully distinct,  elongated,  and  filled  with  nuclei,  apparently  quite  healthy.  The 
white  submucous  substance  was  composed  of  dense  fibre,  and  with  acetic  acid 


ORGANIC    DISEASES    OF    THE    STOMACH.  181 

presented  elongated  nuclei,  arranged  as  in  fibrous  tissue  ;  there  was  no  evi- 
dence of  cancerous  deposit.  The  muscular  tissue  had  the  usual  involuntary 
fibre,  but  firmer  bands  intersected  it.  There  was  no  cancerous  disease  in  any 
part  of  the  body. 

At  both  apices  of  the  lungs  there  was  disorganization ;  there  were  several 
small  vomicte  filled  with  pus,  and  surrounded  by  iron-gray  pneumonia,  and 
with  some  white,  granular  deposit,  resembling  tubercles;  but  no  cancerous 
disease  could  be  found  on  microscopical  examination. 

The  disease  apparently  commenced  in  the  submucous  cellular  tissue, 
and  consisted  of  abnormal  development  of  the  ordinary  fibrous  tissue, 
and  closely  resembled  the  fibrous  growths  of  other  parts.  This 
hypertrophy  of  the  muscular  and  mucous  coats  was  probably  secon- 
darjr,  and  the  result  of  the  obstruction.  The  history  of  the  case,  the 
disappearance  of  the  symptoms,  and  their  recurrence  after  an  interval 
of  more  than  two  years,  are  more  allied  to  fibrous  degeneration  than 
to  cancer. 

The  occurrence  of  phthisis  with  the  diseased  pylorus  is  rare;  the 
patient  was  a  strumous  subject,  and  during  the  exhaustion  consequent 
on  the  disease  of  the  stomach  pneumonia  was  set  up,  and  a  low  or- 
ganized product  effused.  The  age  of  the  patient  was  less  than  that 
in  which  we  generally  find  this  disease,  only  twenty-two;  and  it  is 
doubtful  how  far  her  employment  induced  the  complaint. 

In  another  instance  fibroid  disease  of  the  pylorus  was  found  in  a 
young  man  set.  29,  the  vomiting  had  come  on  about  six  months 
before  death;  and  the  peristaltic  movements  of  the  stomach  were 
visible.  The  stomach  contained  a  large  quantity  of  fluid,  but  its 
surface  was  healthy.  The  pylorus  would  only  admit  a  probe  a 
quarter  of  an  inch  in  diameter.  The  section  showed  fibrous  material 
in  the  submucous  tissue,  but  no  milky  juice  was  present,  and  there 
was  no  ulceration. 

The  pylorus  is  sometimes  found  to  be  remarkably  thickened, 
although  no  symptoms  of  disease  have  been  detected  during  life. 
On  the  post-mortem  table  fibrous  nodules  are  also  occasionally  ob- 
served in  the  submucous  coat;  in  an  instance  of  this  kind  the  growth 
was  supposed  to  be  of  syphilitic  origin,  but  this  opinion  was  not 
borne  out  by  other  appearances ;  the  patient  aged  61,  had  an  athero- 
matous  state  of  the  aorta,  and  embolism  of  the  cerebral  arteries ;  he 
had  pneumonia  also,  and  granular  kidneys.  In  another  case  a 
woman,  aged  64,  who  had  pneumonia  on  the  right  side,  presented  a 
growth  beneath  the  peritoneum  of  the  stomach  on  its  anterior  surface 
and  near  the  pylorus.  The  growth  was  about  the  size  of  a  hazel- 
nut  ;  it  was  easily  enucleated,  and  did  not  involve  any  of  the  mus- 
cular fibres.  It  was  fibrous  under  the  microscope:  several  more 
were  in  the  neighborhood  over  the  stomach,  and  one  or  two  appeared 
to  be  in  the  course  of  the  minute  subperitoneal  vessels. 

Polypoid  Growths  in  the  Stomach. — The  mucous  membrane  of  the 
stomach  not  unfrequently  presents  polypi  attached  to  its  surface; 
several  of  those  which  I  have  examined  have  presented  the  appear- 
ance of  healthy  mucous  membrane,  and  they  had  not  produced  any 
symptoms ;  sometimes  smaller  growths  of  this  character  appear 


182  ORGANIC    DISEASES    OF    THE    STOMACH. 

incorporated  together,  and  closely  resemble  the  appearance  of  com- 
mencing carcinoma;  it  would  seem  that  a  cicatrix  or  some  irritating 
cause  has  in  some  cases  induced  them.  They  are  especially  found 
towards  the  cardiac  extremity  of  the  stomach.  We  have  already 
referred  to  the  views  of  Rindfleisch,  who  considers  them  to  be  ex- 
treme conditions  of  mammillation,  and  traces  them  from  a  rugose 
state  to  pedunculated  masses  of  hypertrophied  mucous  membrane. 
Mammillation  is,  however,  almost  invariably  found,  not  at  the 
cardiac,  but  at  the  pyloric  end  of  the  stomach.  It  is  rare  to  find 
mammillation  at  the  cardia,  and  therefore  most  unlikely  that  it 
should  advance  to  such  an  extreme  stage  as  that  indicated  by  a 
polypoid  growth ;  and,  on  the  other  hand,  the  instances  which  have 
come  under  our  own  notice  have  given  no  evidence  of  such  an  origin, 
and  we  regard  them  as  independent  growths  which  occasionally 
occur  in  the  stomach,  similar  to  those  which  are  found  more  com- 
monly in  other  parts  of  the  intestinal  tract,  more  particularly  in  the 
rectum  and  sigmoid  flexure. 

Cancer  of  the  Stomach. — The  stomach  is  one  of  the  organs  most 
frequently  affected  with  cancer,  and  in  this  frequency  a  remarkable 
contrast  is  presented  when  compared  with  the  rarity  of  strumous 
disease  of  the  same  organ.  Every  form  of  cancer  is  found  to  occur 
in  the  stomach,  but  instances  of  medullary  and  scirrhous  cancer  are 
the  most  numerous,  whilst  epithelial,  villous,  colloid,  and  melanoid 
are  more  rarely  found.  It  is  seen,  however,  that  these  varieties  fre- 
quently pass  the  one  into  the  other,  and  thus,  while  one  part  has 
almost  the  firmness  and  structure  of  scirrhus,  another  has  the  char- 
acteristics of  medullary  growth  ;  and  again,  the  surface  also  of  a 
medullary  cancer  may  have  the  appearance  of  a  villous  structure. 
The  disease  originates  in  the  mucous  membrane  of  the  stomach,  or 
its  submucous  tissue,  or  it  is  propagated  to  the  stomach  by  the  affec- 
tion of  the  glands  in  the  neighborhood  of  the  pancreas;  and  the 
pylorus,  lesser  curvature,  and  cardiac  extremity  are  the  parts  gene- 
rally affected.  It  is  not  necessary  for  me  to  describe  the  ordinary 
characters  of  the  several  forms  of  cancer ;  the  cases  I  have  briefly 
given  show  the  general  appearance  of  the  structures  found  in  them. 
Bamberger,  following  Bokitansky,  describes  the  three  chief  forms  of 
cancer  of  the  stomach,  as  fibrous,  medullary,  and  areolar  or  colloid. 
The  melanotic  and  villous  are  to  be  looked  upon  as  varieties  of  the 
medullary.  Bidder  has  noticed  epithelial  cancer. 

AH  these  forms  of  disease  have  a  tendency,  unlike  ulcers,  to  attack 
the  orifices  of  the  viscus,  and  the  medullary  and  more  particularly 
the  colloid  varieties  are  prone  to  spread  in  the  submucous  tissue. 
Blended,  as  they  often  are,  the  one  with  the  other,  it  becomes  scarcely 
necessary  to  distinguish  between  them  clinically,  but  it  might  per- 
haps be  said  in  relation  to  diagnosis,  that  the  symptoms  vary  ac- 
cording to  the  form  of  disease.  Thus  in  scirrhus  there  is  local 
obstruction  and  dilatation,  and  some  vomiting;  there  may  also  be 
contraction,  so  that  the  calibre  of  the  stomach  is  narrowed,  like  a 
portion  of  intestine.  Alveolar  cancer,  on  the  other  hand,  leads  to 
enormous  thickening,  sometimes  of  the  whole  stomach,  and  the 


ORGANIC    DISEASES    OF    THE    STOMACH. 

vomiting  may  be  the  chief  and  the  only  sympton.  Medullary  cancer 
forms  large  fungoid  masses,  which  may  slough  away  and  thus  no 
obstruction  is  produced ;  in  these  cases  emaciation  is  the  only  symp- 
tom present.  Other  forms  of  tumors,  spindle-cell  sarcoma,  and 
fibroid  tumors  have  been  noticed. 

"We  are  not  acquainted  with  the  determining  cause  of  the  forms 
of  cancer,  or  whether  the  opinion  which  is  maintained  by  some 
pathologists  can  be  established,  that  scirrhus  is  connected  in  its 
origin  with  the  fibrous  tissues  of  the  part ;  medullary  with  the 
mucous  surface  or  gland-structure,  and  colloid  especially  with  the 
latter ;  or  whether  they  are  rather  indications  of  the  intensity  of  the 
morbid  action.  The  part  affected  has  a  modifying  influence  on  the 
character  of  the  disease,  the  epithelial  cancer  of  a  surface  covered 
by  squamous  epithelium  is  different  from  the  same  disease,  where 
the  epithelium  is  columnar;  an  instance  of  differentiation  as  applied 
to  morbid  changes.  It  would  seem  that  scirrhous  disease  is  less  re- 
moved from  normal  nutritive  change  than  medullary  cancer ;  in  the 
one  there  is  a  greater  disposition  to  form  fibroid  tissue,  in  the  other 
the  growth  is  cellular  or  even  nucleolar.  The  vascularity  of  these 
growths  is  very  different,  sometimes  the  whole  structure  is  reddened 
and  it  is  full  of  blood,  and  the  size  of  the  vessel  may  be  so  great  as 
to  cause  active  pulsation,  and  in  this  way  may  simulate  aneurisrnal 
disease.  The  stomach  may  be  affected  secondarily  from  the  liver  or 
peritoneum,  or  cancerous  disease  of  the  stomach  may  be  associated 
with  chronic  abscess  extending  to  the  diaphragm  or  between  the  liver 
and  the  pylorus ;  in  one  instance  this  secondarj'-  suppuration  extended 
up  the  oesophagus  as  high  as  the  division  of  the  trachea;  in  another 
case  under  my  care  in  which  cancerous  disease  of  the  stomach  was 
well  marked,  adhesion  of  the  lesser  curvature  to  the  abdominal  walls 
had  taken  place,  and  at  this  part  a  small  abscess  had  perforated  the 
stomach. 

The  symptoms  of  cancerous  disease  of  the  stomach,  when  a  tumor 
cannot  be  detected  on  manipulative  examination  of  the  abdomen, 
are  often  exceedingly  obscure,  especially  in  the  earlier  stages  of  the 
disease.  It  may  be  convenient  to  divide  the  symptoms  into  three 
classes,  as  they  are  manifested  in  different  stages  of  the  complaint. 
First,  before  the  formation  of  any  perceptible  tumor ;  secondly,  during 
the  development  of  a  growth;  and  thirdly,  the  last  stage,  that  of  dis- 
integration, by  ulceration  or  sloughing.  The  first  symptoms  are 
those  of  dyspepsia;  and  with  these  there  is  often  a  peculiarly  sallow 
and  anxious  expression  of  the  countenance ;  pain  at  the  stomach  may 
be  entirely  absent,  or  there  may  be  severe  gastrodynia;  pyrosis  is 
frequently  present. 

In  the  second  stage  of  the  disease  vomiting  is  generally  the  most 
prominent  symptom,  especially  when  the  disease  is  situated  at  the 
pylorus  or  cardia,  and  the  rejection  of  food  takes  place  according  to 
the  seat  of  obstruction  or  irritation  of  the  gastric  surface,  either  a 
short  time  or  several  hours  after  a  meal.  In  some  instances  the 
vomiting  so  quickly  follows  deglutition  as  to  lead  to  the  supposition 
of  oesophageal  disease.  The  pain  also  becomes  more  severe,  and  is 


184  ORGANIC    DISEASES    OF    THE    STOMACH. 

generally  of  a  more  lancinating  character  than  that  experienced  in 
chronic  ulcer  of  the  stomach.  The  vomited  matters  are  often  frothy 
and  fermenting,  and  present  us  with  abundant  sarcina  ventriculi. 
Hematemesis  is  occasionally  present.  Flatulence  distresses  the  pa- 
tient, and  eructations  are  frequent ;  the  bowels  become  constipated ; 
emaciation  steadily  advances,  and  the  countenance  becomes  haggard 
and  cachectic.  On  careful  examination,  a  tumor  may  generally  be 
felt  at  the  region  of  the  stomach,  or  of  the  pylorus;  it  often  increases 
rapidly,  and  on  account  of  the  wasted  condition  of  the  parietes,  be- 
comes very  apparent. 

In  the  third  stage  of  the  disease  the  symptoms  are  more  severe  and 
the  emaciation  extreme,  and  the  vomiting  of  coffee-ground  substance 
often  precedes  a  fatal  termination.  The  earlier  stages  are  sometimes 
so  slight  that  the  sudden  onset  of  the  last  stage  appears  to  be  the 
commencement  of  the  disease:  thus  a  patient  may  fall  down  after 
some  exertion  and  attribute  the  malady  to  an  accident ;  this  obscu- 
rity of  the  earlier  symptoms  has  been  observed  in  several  cases  of 
villous  cancer,  especially  when  the  orifices  are  free.  The  vomiting 
sometimes  ceases  on  account  of  the  sloughing  of  the  growth ;  the  ob- 
struction thereby  being  removed,  or  the  branches  of  the  pneumogastric 
nerve  being  destroyed,  there  may  be  cessation  of  consequent  irritation  ; 
the  pain,  also,  sometimes  diminishes  from  similar  causes,  and  as  the 
exhaustion  becomes  typhoid  in  its  character,  the  pain  may  entirely 
cease,  or  it  may  be  almost  absent  throughout  the  course  of  the  disease. 
Again,  as  has  been  shown  by  Dr.  Kennedy,1  the  size  of  the  tumor 
may  actually  lessen  from  the  sloughing  process. 

The  immediate  cause  of  death  in  cancer  of  the  stomach  differs 
exceedingly;  the  fatal  termination  may  result  from  exhaustion  con- 
sequent on  the  interference  with  the  absorption  of  nutriment  and  the 
completion  of  the  digestive  function ;  the  exhaustion  may  cause 
comatose  symptoms,  and  what  has  been  designated  serous  apoplexy  ; 
or  after  sloughing  has  taken  place,  the  patient  may  rapidly  become 
prostrate ;  the  breath  is  then  very  offensive,  he  is  seized  with  hic- 
cough, and  in  many  instances,  the  absorption  of  septic  matter  takes 
place,  typhoid  prostration  ensues,  and  lobular  pneumonia  is  the 
result;  or  the  ulcerative  process  may  produce,  in  rare  cases,  fatal 
hemorrhage,  as  in  an  instance  in  which  the  splenic  artery  was 
divided.  Again,  the  extension  of  disease  to  adjoining  parts  may 
materially  modify  the  later  symptoms  of  disease,  by  extension  to 
the  liver,  by  pressure  of  enlarged  glands  on  the  bile-ducts,  thus  pro- 
ducing jaundice,  or  ascites  may  follow  the  implication  of  the  perito- 
neum. The  cancerous  ulceration  sometimes  extends  to  the  actual 
destruction  of  adjoining  tissues,  and  may  pass  into  the  liver ;  in  an 
instance  of  this  kind  a  secondary  opening  made  its  way  into  the 
duodenum,  and  death  resulted  from  hemorrhage.  Communication 
sometimes  takes  place  with  the  transverse  colon  by  a  valvular  or 
sloughy  opening ;  and  if  the  opening  is  large,  feces  also  pass  into 
the  stomach.  In  some  cases  there  is  no  evidence  of  the  passage  of 

>  '  Dublin  Quarterly,'  1851. 


ORGAXIC    DISEASES    OF    THE    STOMACH.  185 

feces  into  the  stomach,  but  merely  gas,  which  greatly  distresses  the 
patient  by  the  fecal  odor  of  the  eructation.  Dr.  Gairdner1  states 
that  fecal  vomiting  is  more  likely  to  take  place  when  the  pylorus  is 
free ;  but  Dr.  Murchison,  on  the"  contrary,  and  we  think  correctly, 
remarks,  that  fecal  vomiting  is  regulated  by  the  size  of  the  commu- 
nication between  the  stomach  and  colon.  The  adhesions  and  slouo-h- 
ing  occasionally  reach  the  external  parietes ;  and  if  a  commuuicatTon 
also  exist  with  the  colon,  an  artificial  anus  is  the  result.  We  have, 
however,  more  frequently  found  this  perforation  of  the  skin  in 
instances  of  cancerous  disease  affecting  primarily  the  transverse 
colon,  and  sometimes  coming  on  after  blows,  &c.  (See  Disease  of 
Colon.) 

The  coffee-ground  substance  to  which  we  have  referred  consists 
of  blood  which  has  oozed  from  the  diseased  surface,  and  has  become 
darkened  by  the  action  of  the  gastric  juice ;  in  some  instances  the 
hemorrhage  is  great,  and  leads  to  a  fatal  termination. 

Cancerous  disease  is  generally  found  to  have  involved  the  glands 
in  the  small  omentutn  at  the  lesser  curvature.  Next  in  frequency 
we  find  the  liver  also  attacked,  sometimes  to  a  very  great  extent; 
the  bile  ducts  may  be  so  implicated  as  to  form  a  mass,  as  it  were, 
imbedding  the  duct ;  and,  in  an  instance  of  this  kind  under  my  care 
in  which  jaundice  existed  for  ten  days  or  a  week  before  death,  it 
was  difficult  to  state  in  which  structure  the  disease  commenced; 
next  the  glands  in  the  anterior  or  posterior  mediastinum  are  infil- 
trated, and  tubercles  may  be  found  on  the  pleura  or  in  the  lungs. 
And  lastly,  other  abdominal  viscera,  the  peritoneum,  kidneys,  or 
spleen,  may  contain  cancerous  growths.  In  cancerous  disease,  also, 
we  observe  that  the  coats  of  the  stomach  themselves  become  infil- 
trated, and  in  this  respect  contrast  with  the  condition  which  we  find 
in  fibroid  degeneration  of  the  pylorus.  In  any  form  of  obstructive 
disease  at  the  pylorus  the  muscular  walls  become  hypertrophied ; 
but  if  there  have  been  ulceration  at  the  pylorus,  and  the  obstruction 
has  subsequently  been  removed,  the  hypertrophy  may  be  exceedingly 
slight ;  so  also  when  the  central  portions  of  the  stomach  or  the  cardia 
are  affected. 

Diagnosis. — It  will  be  found  that  the  symptoms  of  cancer  closely 
resemble  those  of  chronic  ulcer  of  the  stomach  ;  both  are  preceded 
by  a  period  of  dyspeptic  suffering,  during  which  the  diagnosis  is 
exceedingly  obscure.  The  expression  of  the  countenance  in  both  is 
indicative  of  distress,  but  in  chronic  ulcer  there  is  pallor,  in  cancer 
cachectic  sallowness.  Vomiting  of  blood  is  more  frequently  ob- 
served in  ulceration  than  in  cancer;  but  in  the  closing  stages  of 
cancerous  disease  the  rejection  of  coffee  ground  substance  is  of  very 
frequent  occurrence.  The  pain  of  chronic  ulceration  is  often  very 
intense,  even  more  so  sometimes  than  in  cancer;  but  it  is  of  a  gnaw- 
ing character  in  the  former,  more  acute  and  lancinating  in  the  latter; 
again,  the  vomiting  is  often  more  severe  in  ulceration  than  in  cancer. 
The  tumor  of  cancer  is  generally  much  larger  and  more  perceptible 

1  '  Edinburgh  Medical  Journal,'  July,  1855. 


186  ORGANIC    DISEASES    OF    THE    STOMACH. 

than  the  thickening  around  an  ulcer.  The  emaciation  in  both  may 
be  gradual,  progressive,  and  extreme ;  but  the  termination  in  ulcer 
is  more  frequently  by  hemorrhage  or  perforation,  whilst  in  cancer  it 
generally  arises  from  the  typhoid  exhaustion  consequent  on  the  de- 
generation or  sloughing  of  the  growth,  the  absorption  of  decompos- 
ing material  into  the  blood,  or  the  extension  of  disease  to  adjoining 
structures.  Both  diseases  may  occur  at  the  same  age,  but  it  is  more 
common  to  find  chronic  ulceration  at  an  earlier  period  than  cancer. 
This  is  shown  by  contrasting  the  ages  of  the  cases  we  record  of 
chronic  ulcer  of  the  stomach  with  those  of  cancerous  disease  of  the 
same  organ ;  the  average  of  the  former  being  male  and  female  45 
and  40,  and  of  the  latter  52  in  men,  and  in  women  49.  From  40  to 
60  years  is  the  age  at  which  we  are  most  likely  to  have  cancerous 
disease  of  other  organs,  and  this  law  holds  good  with  the  stomach. 
The  age  will  in  some  measure  assist  us  in  the  diagnosis  even  at  the 
later  stages,  but  still  more  in  the  earlier ;  for  the  varied  forms  of 
dyspepsia,  gastrodynia,  pyrosis,  &c.,  are  very  frequent  at  a  period 
long  antecedent  to  the  age  at  which  cancer  generally  manifests 
itself;  dyspepsia  being  exceedingly  common  among  young  females, 
whilst  cancer  is  almost  unknown.  Cancerous  disease  sometimes 
supervenes  upon  a  chronic  ulcer,  so  that  in  these  cases  the  symp- 
toms may  occur  at  an  earlier  period  and  be  of  longer  duration  than 
in  simple  cancerous  disease. 

Taking  our  actual  numbers,  the  comparative  ages  at  each  decade 
are  as  follows : 

Age        10 20 30 40 50 60 70 80 

Cancer  1          2        10        17        24        18          2      =74 

Ulcer  0        14        18  6        15  8          2      =63 

This  comparison  indicates  that  cancerous  disease  occurs  especially 
in  the  later  period  of  life,  whilst  ulcer  occurs  more  frequently  at  an 
earlier  period.  If,  however,  we  remove  instances  of  acute  perfo- 
rating ulcer,  the  proportion  of  ulcers  at  the  earlier  periods  would  be 
greatly  diminished,  and  would  approximate  more  closely  to  the  age 
in  which  cancerous  disease  prevails. 

The  investigations  of  Dr.  Brinton1  on  this  subject  are  very  inte- 
resting and  important ;  he  has  collected  from  varied  sources  a  con- 
siderable number  of  cases  of  cancerous  disease  of  the  stomach  ;  and 
he  shows  that  males  are  more  subject  to  the  disease  than  females  in 
the  proportion  of  2  to  1 ;  out  of  223  cases,  151  were  males,  and  72 
were  females;  in  our  cases,  out  of  74,  52  were  males,  and  22  females ; 
as  to  the  age  of  those  affected,  the  period  given  by  Dr.  Brinton  does 
not  coincide  with  the  age  of  those  which  have  come  under  my  own 
observation  as  compared  with  ulceration  of  the  stomach.  The  follow- 
ing table,  taken  from  the  work  of  the  author  just  mentioned,  shows 
the  liability  to  cancer  and  ulceration  of  the  stomach  at  various  ages : 

Age    10 20 30 40 50 60 70 80 90 

Cancer      £   11§   318   63    88   100    52£   60 
Ulcer     20   51'   49   47   56   80   75   100  ' 

1  'Med.  Chir.  Review.' 


ORGANIC  DISEASES  OF  THE  STOMACH.          187 

The  average  age  of  those  affected  with  cancer  he  mentions  to  be 
51  in  the  male,  and  40J  in  the  female;  and  in  reference  to  the  posi- 
tion, he  confirms  the  well-known  fact,  that  whilst  the  pyloric  portion 
is  the  most  frequent  seat  of  cancer,  the  lesser  curvature  and  poste- 
rior surface  are  the  positions  of  ulcer,  by  the  following  tabular 
statement : 

Position. — In  360  cases. 

Cancer. — 219  Pylorus.  38  Lesser  Curv.  36  Cardia.  13  Stomoch  generally.  11 
Greater  Curv.  11  Posterior  Surface.  11  Anterior  Surface.  4  Middle. 

Ulcer. — 52  Pylorus,  98  Lesser  Curv.  5  Cardia.  0  Stomach  generally.  8  Greater 
Curv.  177  Posterior  Surface.  18  Anterior  Surface.  0  Middle. 

As  to  the  duration  of  chronic  ulcer  compared  with  cancer,  the 
former  disease  extends  over  a  longer  period  of  time ;  in  cancer  the 
disease  may  be  very  rapid ;  in  a  case  under  my  care  the  patient  was 
only  ill  seven  weeks,  and  had  no  pain,  although  there  was  vomiting 
for  three  weeks ;  the  duration  may  be  from  three  to  six  or  twelve 
months,  or  even  two  years ;  in  ulceration,  the  disease  will  be  found 
continuing  three,  four,  or  even  seven  years,  with  varied  accessions 
of  severe  symptoms ;  and  instances  have  occurred  in  which  twenty 
or  more  years  have  intervened  between  the  commencement  of  the 
symptoms  and  their  removal  by  restoration  to  health  or  their  fatal 
termination.  Moreover,  ulceration  is  more  amenable  to  treatment. 

Beside  ulceration  of  the  stomach,  there  are  other  maladies  to  be 
borne  in  mind  in  the  diagnosis  of  gastric  cancer.  In  aneurism  al 
disease  of  the  aorta,  or  of  the  coeliac  axis,  the  pain  is  of  a  different 
kind ;  it  is  less,  if  at  all  affected  by  food ;  it  is  most  severe  at  night, 
and  the  constitutional  symptoms  are  less  decided.  A  systolic  or 
diastolic  bruit  may  be  absent  in  aneurism,  and  pulsation  is  a  very 
deceptive  symptom ;  for  it  is  often  very  marked  in  functional  dis- 
ease of  the  stomach,  and  the  aneurism  may  be  so  near  to  the  dia- 
phragm that  pulsation  cannot  be  felt.  In  aneurism  the  sac  dilates 
uniformly,  and  is  not  affected  by  position,  as  we  may  find  to  be  the 
case  in  diseased  glands  at  the  lesser  curvature,  or  in  an  enlarged  left 
lobe  of  the  liver  reaching  the  aorta  and  so  receiving  pulsation.  In 
some  forms  of  medullary  cancer  the  growth  is  so  vascular  that  it 
pulsates  uniformly,  and  resembles  aneurismal  disease  ;  in  these  cases, 
however,  ihe  gastric  symptoms  are  very  decided.  In  disease  of  the 
glands  at  the  lesser  curvature,  there  is  less  functional  disturbance  of 
the  stomach  than  in  primary  disease  of  that  organ.  So  also  in  dis- 
ease of  the  liver  there  is  an  absence  of  gastric  symptoms,  but  the 
pulsation  of  the  left  lobe  of  the  liver  is  often  deceptive,  as  just  men- 
tioned. In  disease  of  the  pancreas,  the  mischief  is  more  deeply 
seated,  the  stomach  symptoms  are  less  decided,  and  we  not  unfre- 
quently  find  that  jaundice  is  produced  by  obstruction  of  the  bile 
duct  where  it  approximates  to  the  pancreatic  duct.  Disease  of  the 
omentum. — The  omentura  is  sometimes  thickened  by  chronic  inflam- 
matory deposit,  and  forms  a  hard  mass  immediately  below  the 
stomach,  and  may  simulate  disease  of  the  stomach;  when,  however, 
there  is  deposit  in  the  omentum,  the  mass  is  movable,  and  the  diag- 
nosis is  more  easy.  Where  there  is  cancerous  disease  in  the  trans- 


188 


ORGANIC  DISEASES  OF  THE  STOMACH. 


verse  colon  there  is  exhaustion  and  cachexia,  but  the  pain  after  food 
comes  on  at  a  later  period ;  vomiting  is  absent,  unless  there  be 
fistulous  communication  with  the  stomach,  and  there  is  frequently 
discharge  of  blood  from  the  bowel.  Local  peritonitis  and  suppuration 
are  productive  of  great  tenderness  in  the  region  of  the  stomach,  but 
true  gastric  symptoms  are  absent.  In  simple  fibroid  disease  at  the 
pylorus,  the  duration  is  longer,  the  tumor  is  less  distinct,  and  the 
symptoms  are  more  amenable  to  treatment. 

The  evidence  of  cancer  is  most  marked  when  the  pylorus  is  affected, 
and  obstructive  disease  set  up.  Where  this  is  not  the  case,  cancer 
is  sometimes,  however,  found  after  death,  without  having  led  to  any 
special  symptom,  the  patient  having  died  from  another  disease ;  the 
regurgitation  of  glairy,  gelatinous  fluid,  and  gradual  emaciation,  may 
constitute  the  most  prominent  symptoms.  It  sometimes  happens 
that  cancerous  disease  of  the  liver  is  followed  by  infiltration  of  the 
glands  at  the  head  of  the  pancreas,  which  become  united  to  the 
pylorus ;  and,  without  having  infiltrated  the  mucous  membrane, 
these  glands  lead  to  obstruction  at  this  part,  causing  hypertrophy  of 
the  muscular  coat,  and,  by  this  obstruction,  they  simulate  primary 
cancer  of  the  stomach  itself.  The  stomach  is  sometimes  secondarily 
involved  in  cancerous  disease  of  the  oesophagus,  as  in  an  instance  in 
which  two  malignant  ulcers  were  found  in  the  stomach,  and  a  third 
in  the  duodenum.  The  disease  in  the  oesophagus  had  led  to  the 
prominent  symptom  of  dysphagia,  and  produced  sloughing  in  the 
adjoining  lung.  When  the  cardiac  extremity  is  diseased,  the  vomit- 
ing frequently  occurs  so  immediately  after  taking  food  that  the 
symptoms  resemble  cancerous  disease,  or  some  other  form  of  obstruc- 
tion of  the  oesophagus.  In  some  instances  the  pneumogastric  nerves 
may  be  traced  through  the  medullary  tumors  of  the  stomach ;  and 
either  the  nerve-fibres  may  be  found  to  present  their  ordinary 
microscopical  appearance  or  be  entirely  destroyed.  It  is  this  de- 
struction of  the  nerve-fibres  which  sometimes  lead  to  a  cessation  of 
the  pain  and  extreme  irritability  of  the  stomach. 

The  following  table  of  cases,  which  have  occurred  for  the  most 
part  in  Guy's  Hospital  during  the  last  twenty  years,  shows  the  sex 
of  the  patient,  the  form  of  the  disease,  the  cause  of  death,  the  con- 
dition of  the  stomach  as  to  dilatation  or  contraction,  and  the 
complications  or  secondary  affections.  Out  of  79  cases  the  cancer 
occurred  at  the 


Pylorus  in 
Lesser  curvature  in 
Cardia  in 
Anterior  wall  in 
General  in 


41 

11 

10 

5 

4 


Centre  in 
Multiple  in 
Greater  curvature  in 
Cardia  and  pylorus  in 
Not  stated  in   . 


ORGANIC    DISEASES    OF    THE    STOMACH 


189 


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190 


ORGANIC    DISEASES    OF    THE    STOMACH. 


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192  ORGANIC    DISEASES    OF    THE    STOMACH. 

In  the  treatment  of  cancer  of  the  stomach  the  same  remedies  which 
have  been  mentioned  in  chronic  ulceration  may  afford  great  com- 
fort to  the  patient,  although  they  are  ineffectual  as  a  means  of  cure. 

It  is  of  the  greatest  importance  carefully  to  regulate  the  diet  of 
the  patient ;  but  it  is  of  no  use,  and  indeed  the  exhaustion  is  in- 
creased, by  the  continued  administration  of  food  that  cannot  be 
digested  or  pass  the  pylorus.  If  there  be  pain,  and  especially  if 
there  be  obstruction  at  the  orifices,  fluid  diet  only  should  be  taken, 
and  of  a  kind  that  does  not  easily  undergo  fermentative  change ; 
milk  and  simple  soup,  as  mutton  broth,  chicken  broth,  eggs,  &c., 
are  the  best,  and  some  fresh  lemon  juice  with  water  to  supply  the 
place  of  vegetables ;  farinaceous  food,  although  unirritating,  is  often 
followed  by  flatulent  distension ;  sugar  should  be  avoided,  and 
these  patients  are,  as  a  rule,  better  without  ardent  spirits.  A  small 
quantity  of  wine,  such  as  good  Marsala,  may  sometimes  be  taken 
with  advantage,  and  although  ardent  spirits,  as  brandy  or  whiskey, 
do  not  ferment,  they  are  more  irritating  to  the  mucous  membrane 
and  to  the  liver. 

Medicines  which  soothe  the  mucous  membrane  and  which  check 
fermentative  action  are  often  of  great  service.  Carbonate  or  nitrate 
of  bismuth,  with  carbonate  of  soda  and  chloric  ether,  may  be  given 
with  almond  emulsion  or  with  tragacanth  powder  and  water;  if 
there  be  pain  very  small  doses  of  morphia  may  be  added.  The  dis- 
advantage of  the  use  of  bismuth  is  the  constipating  effect  that  it  has 
upon  the  bowels,  for  although  the  quantity  of  food  taken  may  be 
small,  there  are  abundant  alvine  excretions,  and  if  the  transverse 
colon  be  loaded  and  distended  the  gastric  symptoms  are  increased. 
Magnesia  medicines  may  be  given  to  obviate  this  effect,  or  simple 
injections  used.  Castor  oil  is  often  easily  taken  when  mixed  with 
tragacanth  powder  and  an  aromatic  water.  Pills  are  better  avoided 
in  pyloric  disease  and  in  malignant  ulceration  ;  they  do  not  dissolve 
in  the  stomach,  and  sometimes  irritate  the  diseased  part.  In  one 
instance,  after  several  pills  had  been  administered  and  retained 
for  four  or  five  days,  they  were  vomited  up  almost  unchanged. 
Morphia  in  small  doses  alone  or  with  alkalies  is  often  a  great  relief 
to  the  patient,  or  it  may  be  combined  with  belladonna.  If  there  be 
much  fermentative  action  and  distension,  the  sulphite  or  hypo- 
sulphite of  soda  is  very  useful  in  9j  doses,  along  or  with  the  nar- 
cotics just  mentioned.  Mineral  acids  often  distress  the  patient  and 
increase  irritability  of  the  stomach,  and  the  mildest  tonics,  as  ca- 
lumba,  cascarilla,  increase  vomiting  and  do  no  good,  so  also  the 
stronger  tonics,  as  quinine ;  sometimes  very  minute  doses  of  steel, 
as  the  amonia-citrate,  are  tolerated,  and  if  there  be  hemorrhage, 
astringents,  as  the  tincture  of  iron,  alum,  or  tannic  acid,  may  be 
given.  If  the  stomach  refuse  these  remedies,  in  cases  of  great  irrita- 
bility, opiates  may  be  used  as  suppositories.  External  remedies 
afford  some  relief,  and  the  chloroform  liniment  alone,  or  with  bella- 
donna liniment,  well  shaken  together,  may  be  used  on  linen  or 
spongio-piline.  Nutrient  injections  often  prolong  life  and  relieve 
the  patient  from  much  gastric  distress ;  flatulence,  distension,  and 


ORGANIC    DISEASES    OF    THE    STOMACH.  193 

the  vomiting  of  food,  are  thus  avoided,  and  the  sufferer  is  nourished 
by  this  imperfect  means  more  than  by  ineffectual  attempts  to  induce 
normal  digestion. 

CASE  LXVI.  Scirrhorts  Pylorus.  Carcinomatons  Tubercles  in  the  Liver, 

Spleen,  and  Kidney,  and  on  the  Diaphragm Edgar  C — ,  set.  40,  was  a 

cooper,  and  till  the  attack,  for  which  he  applied  to  the  hospital,  he  had  enjoyed 
good  health.  Four  months  previously  sickness  had  come  on,  and  it  took 
place  generally  a  few  hours  after  taking  food,  but  sometimes  he  was  able  to 
retain  three  or  four  meals  in  succession.  A  tumor  could  be  felt  at  the  region 
of  the  pylorus ;  there  was  great  emaciation,  and  he  slowly  sank. 

Inspection  twenty-six  hours  after  death — The  thoracic  viscera  were  quite 
free  from  disease.  There  were  several  white,  firm  tubercles  in  the  abdo- 
men, on  the  under  surface  of  the  diaphragm,  opposed  to  the  liver;  similar 
tubercles  were  found  in  the  sheath  of  the  right  kidney,  and  a  rather  larger 
one  on  the  surface  of  the  spleen.  In  the  liver,  on  its  under  surface,  were 
several  tubera,  about  half  an  inch  in  diameter,  with  raised  and  well-defined 
edges  ;  the  remaining  portion  of  the  viscus  was  healthy.  The  stomach  was 
very  much  distended  with  air  and  dark,  redish-colored  fluid ;  at  its  lesser 
curvature  a  small  tubercle  was  observed  on  the  peritoneal  surface ;  several  of 
the  nerves  at  the  lesser  curvature  were  involved  in  this  growth.  On  opening 
the  stomach  it  was  found  to  contain  fluid,  as  before  mentioned,  smelling  very 
strongly  of  lactic  acid.  At  the  pylorus  was  found  a  hard  mass,  composed 
principally  of  glands,  and  on  the  inferior  surface  the  pylorus  itself  was  infil- 
trated with  dense  cancerous  deposit.  The  valve  was  contracted  so  as  only  to 
admit  a  large-sized  catheter,  and  its  mucous  membrane  was  destroyed  by 
ulceration  ;  the  ulcer  extended  into  the  stomach  ;  its  edges  were  raised,  and 
in  some  parts  were  vascular.  The  muscular  coat  could  be  traced  nearly  to 
the  pylorus,  somewhat  thickened,  but  in  a  healthy  condition ;  it  then  became 
involved  in  the  cancerous  infiltration,  and  was  of  a  whitish  color ;  at  the 
pylorus  both  muscular  and  mucous  coats  were  destroyed,  and  semi-cartilagi- 
nous tissue  only  remained  for  about  three-quarters  of  an  inch.  The  mucous 
membrane  and  the  infiltrated  tissue  presented  well-marked  cancer-cells,  with 
large  nuclei,  and  aggregated  cells,  as  in  epithelial  cancer;  the  dense  tissue 
beneath  was  gland-tissue,  infiltrated  with  scirrhous  product.  The  duodenum 
contained  bilious  matter  and  a  considerable  number  of  white  grains,  which 
were  at  first  supposed  to  be  Brunner's  glands,  but  they  were  found  to  consist 
of  solitary  glands.  The  pancreas  and  the  remaining  portion  of  the  intestine 
were  healthy ;  there  was  some  infiltrated  glands  at  the  commencement  of  the 
rectum,  but  the  mucous  membrane  was  sound. 

The  symptoms  in  this  case  were  well  marked,  and  it  was  evident 
that  there  was  obstructive  disease  at  the  pylorus.  The  examination 
of  the  growth  at  that  part  showed  great  resemblance  to  epithelial 
cancer ;  the  glands,  however,  in  the  neighborhood  of  the  pancreas, 
which  were  infiltrated,  and  the  cancerous  tubera  found  in  the  liver 
and  on  the  peritoneum,  presented  the  character  of  ordinary  scirrhus. 

It  was  an  interesting  fact  to  find  at  the  rectum,  a  frequent  seat  of 
cancer,  the  glands  infiltrated  ;  but  the  lumbar  and  mesenteric  glands 
were  free  from  disease. 

CASE  LXVII.   Medullary  Cancer  of  the  Stomach,  having  a  villous  char. 

acter Thomas  G — ,  ait.  62,  had  been  a  shepherd  at  Shoreham,  and  eight 

months  before  admission  experienced  flatulence,  loss  of  appetite,  and  dys- 
pepsia.    For  six  weeks  he  had  been  very  ill,  and  he  ha:l  suffered  occasionally 
13 


104  ORGANIC    DISEASES    OF    THE    STOMACH. 

from  vomiting.  He  had  no  pain  or  uneasiness  at  the  stomach  ;  but  he  was 
emaciated,  and  there  was  a  turner,  about  the  size  of  an  orange,  situated  just 
above  the  umbilicus,  but  separable  from  the  liver,  and  slightly  movable  on 
respiration.  Slight  oedema  of  the  ankles  came  on  before  death,  which  took 
place  six  weeks  after  admission. 

On  inspection  the  thoracic  viscera  were  healthy.  On  opening  the  abdomen 
a  tumor,  about  the  size  of  an  orange,  was  found  to  be  situated  at  the  pyloric 
end  of  the  stomach  ;  the  gall-bladder  above  was  adherent  to  it,  accounting 
for  the  movements  of  the  tumor  with  the  liver;  and  below,  the  transverse 
colon  and  omentum  were  inseparably  united  with  it.  The  pylorus  appeared 
(  mbraced  by  the  growth  extending  from  above  and  below,  and  on  opening  the 
stomach  the  whole  of  its  circumference  was  found  affected.  The  intestines  were 
collapsed  ;  the  liver  was  healthy,  but  its  peritoneal  coat  was  thickened  at  its 
lower  margin.  The  gall-bladder  was  empty ;  the  pancreas  was  not  at  all 
affected,  though  in  close  contact  with  the  tumor ;  the  kidneys  were  small, 
atrophied,  and  contained  cysts.  There  were  several  gastric  glands  in  the  neigh- 
borhood of  the  lesser  omentum,  which  were  infiltrated  with  cancer,  but  the  lum- 
bar and  bronchial  glands  were  not  affected.  On  opening  the  stomach  it  pre- 
sented a  large  medullary  growth,  extending  about  two  inches  from  the  pylorus 
into  the  stomach,  involving  the  whole  of  the  valve,  and  forming  a  projecting, 
soft,  tubercular  ring,  vascular  and  extending  into  the  duodenum.  The 
pylorus  itself  would  admit  the  tip  of  the  little  finger.  This  growth  was  soft, 
of  a  yellowish-white  color,  and  about  one  inch  in  thickness.  At  the  margin 
the  muscular  coat  could  be  traced  into  it,  forming  a  semi-transparent  layer, 
about  a  quarter  of  an  inch  in  thickness,  but  evidently  infiltrated  with  cancer ; 
at  the  edge  of  the  cancer  the  muscular  coat  suddenly  became  of  its  usual 
thickness,  showing  that  there  had  not  been  great  obstruction,  so  as  to  lead 
to  much  hypertrophy  of  that  layer.  Near  to  the  lesser  curvature  was  another 
growth,  projecting  from  the  mucous  membrane,  soft,  irregular,  on  its  surface, 
and  covering  about  a  square  inch  in  extent ;  it  was  about  half  an  inch  in 
thickness,  and  at  its  edges  presented  small,  soft,  tubercular  growths,  projecting 
from  the  membrane.  The  mucous  coat,  involved  in  carcinomatous  disease, 
could  be  dissected  away  from  the  muscular,  till  near  the  centre  of  the  growth, 
where  all  the  tissues  were  firmly  united  together,  and  large  vessels  could  be 
seen  passing  into  the  cancerous  mass.  Near  this  part,  vessels  full  of  blood 
extended  to  its  circumference,  giving  it,  in  some  parts,  a  red  and  vascular 
appearance. 

Microscopic  examination  showed  that  the  mass  consisted  of  cells 
and  nuclei,  varying  in  size  ;  some  cells  were  about  the  size  of  healthy 
epithelium.  The  nuclei  were  large,  very  distinct,  and  some  had 
double  nucleoli.  On  taking  a  portion  of  the  surface  of  the  tumor, 
and  floating  it  in  water,  numerous  rod-like  processes  were  observed, 
extending  for  a  considerable  distance  from  it,  having  the  character 
of  villi ;  and  they  gave  to  the  margin  of  the  growth  a  flocculent 
appearance.  These  villi  were  found  to  contain  numerous  nuclei. 

At  the  margin  of  the  growth  the  gastric  follicles  were  much  de- 
generated, and  they  were  in  some  parts  distended,  but  without  cells ; 
in  other  parts,  only  the  termination  of  the  follicles  could  be  seen ; 
again,  some  of  the  follicles  had  an  irregular  outline,  and  presented 
crystals  on  the  surface  of  the  membrane.  Around  the  former  por- 
tion of  atrophied  follicles  there  was  fibrous  tissue,  arranged  in 
meshes,  and  with  acetic  acid  the  fibres  appeared  minutely  granular. 


ORGANIC    DISEASES    OF    THE    STOMACH.  195 

The  whole  appearance  of  this  structure  was  that  of  medullary 
cancer ;  it  was  composed  principally  of  nuclei,  and  had  affected  the 
pyloric  extremity,  leading  to  symptoms  of  obstruction.  There  was 
some  infiltration  of  the  adjoining  glands;  but  the  remaining  viscera 
were  healthy.  The  growth  appeared  to  have  commenced  in  the 
mucous  membrane.  It  was  on  the  examination  of  the  surface,  how- 
ever, that  the  resemblance  to  villous  cancer  was  manifested ;  the 
surface  had  a  flocculent  appearance,  and  microscopical  examination 
showed  that  this  arose  from  villous  processes  extending  from  the 
surface. 

This  case  appeared  to  stand  in  an  intermediate  position  between 
medullary  and  villous  cancer  ;  and  it  confirms  the  opinion  expressed 
by  Sir  James  Paget,  that  the  latter  may  be  merely  a  variety  of  the 
more  common  form. 

As  to  the  symptoms,  several  months  of  dyspepsia  were  passed ; 
the  health  then  rapidly  failed,  and  prostration  of  strength,  emacia- 
tion, and  occasional  vomiting  were  the  principal  indications  of  dis- 
ease. It  was  remarkable  to  observe  the  absence  of  pain  or  even 
uneasiness  of  the  stomach. 

CASE  LXVIII.  Cancerous  Disease  of  the  Stomach.  Exhaustion.  Epi- 
leptic Fit.  Coma.  Serous  Sub-arachnoid  Effusion.  Some  thickening  of 
the  Arachnoid — William  G — ,  aged  64,  was  admitted  into  Guy's  Hospital, 
under  my  care,  November  23d,  1870.  He  was  a  married  man,  a  mason,  his 
liabits  of  life  had  been  temperate,  and  he  had  never  contracted  syphilis. 
Five  years  previously  he  had  been  in  the  hospital  for  rheumatism,  but  had 
otherwise  enjoyed  good  health.  About  the  commencement  of  October  he 
began  to  suffer  from  aching  pain  in  the  chest  and  pains  in  the  limbs.  He 
then  lost  his  appetite,  and  the  sight  of  food  produced  nausea ;  although  he 
had  been  troubled  with  retelling,  he  had  never  vomited.  The  symptoms  be- 
came more  severe,  till  the  period  of  admission.  He  was  pale  and  emaciated, 
his  mind  not  very  active  ;  his  complaint  was  of  constant  burning  pain  at  the 
pit  of  the  stomach,  and  he  suffered  from  great  thirst  and  from  nausea.  No 
tumor  could  be  felt  at  the  region  of  the  stomach ;  there  was  some  tenderness, 
and  the  recti  muscles  were  rigid.  The  thoracic  viscera  were  normal,  but  the 
heart  was  feeble;  pulse  72  ;  temperature  99°.  The  bowels  were  regular; 
the  urine  normal.  There  was  no  enlargement  of  the  liver,  but  he  complained 
of  pain  when  percussion  WHS  made.  The  spleen  was  normal.  He  \v;is 
ordered  the  sedative  mixture  of  bismuth  (Guy's),  and  for  diet,  arrowroot, 
beef  tea,  &c.,  with  brandy  gij.  The  pain  in  the  stomach  was  soon  relieved, 
and  he  had  inclinations  for  food.  December  7th — The  recti  muscles  of  the 
abdomen  still  remained  stiff  and  hard,  but  there  was  increased  pulsation  at 
the  scrobiculus  cordis.  He  was  allowed  mutton  chops,  at  first  pounded,  and 
afterwards,  at  his  request,  solid.  21st — The  countenance  had  a  wasted, 
haggard  expression  ;  he  was  able  to  retain  the  solid  meat  diet ;  the  abdomen 
was  less  contracted  and  a  small  round  growth  coull  be  felt  just  beneath  the 
cartilage  of  the  seventh  rib,  Tiear  the  cardiac  end  of  the  stomach.  It  could 
be  moved,  and  on  pressure  communicated  pulsation.  Castor  oil  was  given, 
and  Dr.  Moxon  afterwards  gave  croton  oil  to  unload  the  bowels,  but  the 
swelling  remained  the  same.  The  moral  and  intellectual  perceptions  of  the 
patient  were  found  to  be  blunted ;  he  walked  out  of  the  ward  at  night,  and 
supposed  that  he  had  been  walking  for  an  hour  or  two ;  afterwards  tried  to 
get  into  the  next  patient's  bed  ;  placed  his  mutton  chops  under  the  bed,  as  he 


196  ORGANIC    DISEASES    OF    THE    STOMACH. 

said,  to  feed  the  mice.  The  liquor  bismuthi,  with  citrate  of  ammonia  and 
iodide  of  potassium,  were  ordered.  On  21st  .January  his  mind  became  more 
clear;  he  complained  of  pain  in  the  abdomen,  and  said  that  he  was  \rrv 
hungry.  The  abdomen  became  fuller,  more  tense,  and  fluctuation  could  be 
felt.  The  growth  in  the  neighborhood  of  the  stomach  became  obscured  by  the 
effusion. 

In  February  I  again  took  charge  of  the  ward  ;  the  patient  was  then  in  a 
conscious  state,  and  complained  of  pain  in  the  abdomen,  especially  in  the 
gastric  region  ;  there  was  diarrhoea,  which  was  checked  by  logwood  mixture. 
His  sense  of  hearing  became  blunted,  and  he  had  a  humming  noise  in  both 
ears.  2oth — The  abdomen  was  more  full  and  tense ;  there  was  a  slight  fit 
in  the  morning,  the  patient  lost  consciousness  for  a  short  time,  and  on  recov- 
ering retched  a  good  deal.  There  was  pain  over  the  whole  abdomen.  The 
left  side  of  the  face  was  slightly  paralyzed  ;  grasp  of  the  hand  feeble  ;  the 
patient  seemed  very  drowsy.  On  March  3d  he  got  out  of  bed  in  the  night 
and  fell  down  in  the  ward.  He  complained  afterwards  of  severe  pain 
over  the  lower  ribs  on  the  right  side.  No  broken  rib  could  be  detected,  but 
a  flannel  bandage  was  placed  around  the  chest.  On  March  Gth  he  had 
rigors;  he  scarcely  understood  anything  that  was  said  to  him.  On  the  loth 
the  urine  was  found  to  be  albuminous ;  the  pulse  was  90,  and  very  feeble ; 
he  remained  in  a  state  of  stupor,  from  which  he  could  sometimes  be  partially 
roused,  but  he  almost  at  once  relapsed  into  a  semi-comatose  state.  lie  fre- 
quently muttered  incoherently.  Milk  with  egg  and  brandy  were  given.  He 
swallowed  food  well,  and  there  was  no  vomiting.  He  died  at  halt-past  seven 
in  the  morning  of  the  20th. 

An  inspection  was  made  in  the  afternoon  of  the  same  day.  The  brain 
was  small  and  soft,  there  was  serous  effusion  between  the  convolutions,  and 
the  fluid  in  the  lateral  ventricles  was  in  excess.  There  was  some  thicken- 
ing of  the  membranes  on  the  surface.  The  left  pleura  was  adherent:  The 
lung  was  cedematous,  and  a  patch  of  recent  pneumonia  was  found.  Numer- 
ous hard,  fibrinous  nodules  were  observed  on  the  surface  of  the  pleura,  espe- 
cially at  the  upper  part.  The  oesophagus  was  ulcerated.  At  the  cardiac  end 
of  the  stomach  there  was  a  large  mass  of  encephaloid  cancer,  two  inches 
in  depth,  very  soft,  and  partially  ulcerated.  The  peritoneum  contained  six 
pints  of  greenish  serum,  and  there  were  small  lymph  granulations.  The 
spleen  was  soft ;  the  kidneys  were  healthy  ;  there  was  no  deposit  in  the  liver. 

The  termination  of  this  case  was  peculiar ;  as  the  exhaustion  in- 
creased an  epileptiform  attack  came  on,  probably  from  the  atrophy 
of  the  brain,  with  some  arachnoid  irritation,  the  faculties  became 
blunted,  and  the  patient  slowly  sank ;  at  this  time  the  gastric  symp- 
toms were  necessarily  obscured,  and  if  the  patient  had  been  seen 
for  the  first  time  after  the  occurrence  of  the  cerebral  symptoms,  the 
nature  of  the  malady  might  have  been  quite  overlooked.  The  pre- 
sence of  albumen  in  considerable  quantity  led  us  to  suppose  that  the 
kidneys  were  diseased,  and  had  some  connection  with  the  epilepti- 
form attack  and  subsequent  persistent  drowsiness ;  the  post-mortem 
examination  showed  that  the  albuminous  urine  was  an  effect  of  the 
fit  rather  than  its  cause,  for  the  kidneys  were  pronounced  to  be 
healthy.  It  is  unusual  to  find  such  extensive  disease  at  the  cardia  with- 
out vomiting  or,  at  least,  regurgitation  of  food  ;  but  the  patient  only 
experienced  dry  retching.  The  food  having  passed  into  the  stomach 
no  further  impediment  was  met  with,  as  the  pylorus  was  free.  On 


ORGANIC    DISEASES    OF    THE    STOMACH.  197 

admission  the  growth  could  not  be  felt,  partly  from  the  rigidity  of 
the  parietes,  and  in  part  from  its  small  size,  but  as  the  muscles"  be- 
came relaxed  and  the  growth  increased  in  size,  a  hard  pulsating 
nodule  could  be  felt ;  the  pulsation  was  communicated  by  contact 
•with  the  aorta,  beneath ;  after  a  few  weeks  the  tumor  was  again  lost 
to  the  touch  by  the  serous  effusion  into  the  peritoneum.  The  treat- 
ment throughout  was  purely  palliative.  The  movable  character  of 
the  tumor  when  first  discovered  whilst  Dr.  Moxon  had  charge  of  the 
ward,  led  to  the  free  use  of  purgative  medicine  to  remove  any  pos- 
sible source  of  fallacy  in  the  local  retention  of  a  fecal  mass  in  the 
larger  bowel ;  the  true  character  of  the  disease,  however,  being  fully 
recognized. 

CASE  LXIX.  Villous  Cancer  of  the  Stomach.  Perforation.  Extension 
into  the  Left  Lobe  of  the  Liver.  Secondary  opening  into  the  Duodenum. 
Death  from  sudden  Hemorrhage  into  the  Stomach. — Elizabeth  C — ,  jet.  56, 
admitted  into  Clinical  Ward,  October  12th,  1870.  She  had  resided  near  Plum- 
stead,  had  worked  hard,  and  had  suffered  privation.  She  dated  her  illness 
thirteen  months  back,  when  on  lifting  a  large  tub  of  water  she  "felt  something 
snap  in  her  left  side,  which  gave  her  great  pain,  and  made  her  feel  very  faint." 
For  a  week  she  was  unable  to  do  any  work  on  account  of  the  seventy  of  the 
pain  ;  hot  fomentations  afforded  partial  relief.  About  a  week  after  the  acci- 
dent she  vomited  about  "•  half  a  wash-hand  basinful"  of  dark  fluid  like  coffee 
grounds  mixed  with  clots  of  blood,  and  she  continued  to  vomit  similar  dark 
fluid  every  fortnight  till  the  time  of  admission.  She  experienced  pain  in  the 
side  even  when  lying  quiet,  but  it  was  rendered  much  more  severe  when  she 
moved  about  or  coughed.  The  appetite  was  bad,  and  directly  after  she  took 
any  food  great  pain  in  the  region  of  the  stomach  came  on,  and  in  about  half 
an  hour  it  was  rejected  with  black  fluid.  She  lost  flesh,  and  became  much 
paler.  The  bowels  had  been  regular,  the  motions  sometimes  quite  black,  at 
other  times  of  a  clay  color.  She  was  a  thin  and  cachectic  woman,  with  an 
anxious  expression  of  countenance.  She  complained  of  great  pain  in  the 
left  hypochondriac  region,  extending  to  the  epigastric  and  right  hypochondriac 
spaces ;  the  pain  was  increased  by  pressure,  and  was  greatest  three  inches 
below  the  left  nipple  and  four  inches  from  the  median  line.  There  was  dul- 
ness  at  the  ensiform  cartilage.  Pain  was  described  as  of  a  stabbing  charac- 
ter, and  as  commencing  on  the  left  side  and  extending  to  the  right.  She  had 
a  slight  cough,  but  respiration  was  normal.  There  was  no  bruit  with  the 
heart.  The  urine  was  free  from  both  albumen  and  sugar. 

On  inquiry  it  was  found  that  for  several  months  before  the  hemorrhage 
from  the  stomach  took  place  she  had  suffered  from  pain,  which  was  relieved 
by  brandy  or  gin,  but  that  she  had  been  a  temperate  woman. 

Leeches  were  applied  to  the  stomach,  and  conium  and  blue  pill  and  the 
sedative  solution  of  bismuth  were  ordered.  She  had  spare  diet.  On  the  24th 
meat  diet  was  allowed,  the  pain  having  subsided,  but  it  produced  at  once  a 
return  of  suffering.  The  cough  was  rather  troublesome.  On  November  1st 
she  again  had  vomiting,  and  opium  was  given  at  night.  Oil  the  7th  diarrhoea 
came  on,  but  was  checked  by  logwood  and  opium,  etc.,  and  she  continued  to 
lose  flesh.  On  the  1st  December  I  took  charge  of  the  ward.  She  was  then 
emaciated  and  cachectic ;  there  was  defined  hardness  and  tenderness  at  the 
scrobiculus  cordis,  as  if  the  left  lobe  of  the  liver  was  implicated.  Opium  three 
times  a  day  gave  considerable  relief  for  a  time,  but  she  had  repeated  attacks 
of  diarrhoea  and  pain  across  the  abdomen,  and  she  steadily  lost  strength. 
Bismuth,  krameria,  &c.,  afforded  partial  relief,  but  she  became  very  despond- 


198  ORGANIC    DISEASES    OF    THE    STOMACH. 

ing.  For  some  days  the  pain  would  cease  altogether.  On  the  20th  January 
she  was  free  from  pain,  the  pulse  compressible,  the  abdomen  contracted,  but 
during  the  night  vomiting  and  diarrhoea  supervened,  and  she  gradually  sank. 

Inspection  was  made  on  the  following  day.  The  chest  was  healthy ;  the 
heart  wasted.  Abdomen. — The  peritoneum  was  healthy,  but  there  were  firm 
old  adhesions  between  the  stomach  and  the  left  lobe  of  the  liver  (the  part  felt 
during  life),  but  the  parietes  were  free;  the  stomach  was  half  filled  with 
blood  clot  and  serum  ;  the  intestines  were  also  filled  with  blood.  On  opening 
the  stomach  a  large  villous  cancerous  growth,  five  to  six  inches  in  length, 
was  found  at  the  lesser  curvature  on  the  posterior  aspect  of  the  stomach.  It 
had  a  villous  flocculent  appearance,  its  edges  were  raised,  and  an  inch  in 
thickness.  Some  of  the  villi  floated  loose  in  the  clot ;  it  was  of  a  pale  yellow 
color,  softened,  and  in  the  centre  was  a  slough  ;  at  the  central  sloughing  por- 
tion the  walls  of  the  stomach  had  become  perforated  and  the  sac  of  the  lesser 
omentum  opened  ;  a  secondary  and  also  sloughy  opening  had  been  formed 
into  the  duodenum  immediately  beyond  the  pylorus.  The  valve  itself  was 
unaffected.  The  opposed  surface  of  the  liver  from  the  cavity  behind  the 
stomach  had  become  affected  by  direct  continuity,  and  the  disease  had  de- 
stroyed a  considerable  portion  of  the  left  lobe  of  the  liver  ;  about  half  an  inch 
in  thickness  of  liver-structure  only  remained.  The  centre  of  this  liver  disease 
was  sloughing;  it  was  bounded  by  sprouting,  soft,  cancerous  growth,  which 
extended  into  the  gland,  and  was  itself  surrounded  by  a  more  dense  whitish 
zone  of  firmer  tissue.  The  rest  of  the  liver  was  fatty  and  congested ;  the 
ducts  were  free.  There  was  no  secondary  affection  of  the  glands.  The 
spleen  was  normal.  u  When  floated  in  water  the  villosities  were  very  long 
and  beautiful,  and  were  full  of  large  vessels  injected  with  blood  ;  the  ramifi- 
cations of  these  could  easily  be  seen  by  the  naked  eye ;  they  were  soft  and 
easily  detached." 

Under  the  microscope  the  growth  was  found  to  consist  of  an  immense 
aggregate  of  cancer  cells  and  nuclei,  with  very  little  fibroid  or  elongated  cell- 
development. 

This  case  was  one  possessing  many  points  of  great  interest.  The 
onset  was  peculiar  ;  a  short  period  of  dyspepsia  was  followed  by  sud- 
den hemorrhage  from  the  stomach.  It  is  probable  that  a  growth  had 
already  formed  in  the  stomach,  and  that  the  sudden  strain  upon  the 
vessels  during  the  muscular  effort  led  to  rupture  of  their  coats  and 
effusion  of  blood ;  hemorrhage  may  also  have  occurred  into  the  sub- 
mucous  cellular  tissue. 

After  a  short  time  perforation  took  place,  but  it  was  at  the  poste- 
rior part  of  the  stomach,  and  extravasation  was  localized  by  adhe- 
sions. It  is,  however,  possible  that  the  perforation  occurred  at  the 
period  when,  great  muscular  exertion  was  made,  and  this  rupture 
was  the  cause  of  the  severe  pain.  The  local  mischief  extended  to  the 
liver ;  the  cancerous  disease  had  involved  the  gland,  and  the  slough- 
ing arose  from  the  loss  of  vitality  in  the  new  deposit  rather  than  from 
destruction  of  the  liver  structure  itself.  This  was  shown  by  the 
margin  of  cancer  growth  in  the  liver.  As  disease  advanced  the 
opening  into  the  stomach  not  being  perfectly  free,  burrowing  took 
place  behind  the  pylorus,  in  the  direction  of  the  duodenum,  and  an 
opening  had  formed,  as  before  described,  into  the  first  part  of  that 
portion  of  small  intestine.  The  perforation  of  some  fresh  vessels 
and  the  consequent  hemorrhage  were  the  immediate  causes  of  death. 


ORGANIC  DISEASES  OF  THE  STOMACH.          199 

This  instance  furnishes  another  example  of  the  insidious  com- 
mencement of  cancerous  disease  of  the  stomach,  but  the  whole 
course  was  obscure,  and  the  more  so,  as  vomiting  was  greatly  less- 
ened by  the  removal  of  all  obstruction  at  the  pyloric  valve  by  the 
secondary  opening  just  described.  Distension  of  the  stomach  from 
gaseous  evolution  tends  greatly  to  increase  the  severity  of  the  vomit- 
ing in  organic  disease  of  the  pylorus.  In  this  instance  a  free  dis- 
charge of  gas  could  take  place  into  the  duodenum  by  means  of  the 
secondary  opening  beyond  the  pylorus.  The  comparative  freedom 
from  pain  was  also  remarkable ;  in  fact,  the  patient  was  so  destitute 
of  pain  that  one  of  my  clinical  clerks  suggested  whether  there  was 
not  a  great  deal  of  hysterical  exaggeration  in  her  state. 

CASE  LXX.  Villous  Growth  of  the  Stomach.  Cirrhosis.  Ascites — Isa- 
bella D — ,  aet.  65,  was  a  married  woman,  who  had  been  accustomed  to  take 
spirits,  but  she  stated  that  she  had  been  in  good  health  till  six  months  pre- 
viously, when  she  caught  cold,  which  was  succeeded  by  cough,  by  shortness 
of  breath,  and  by  burning  pain  at  the  scrobiculus  cordis.  Seven  weeks  before 
admission,  her  legs,  and  afterwards  the  abdomen,  began  to  swell ;  diarrhoea, 
great  prostration,  and  syncope  came  on,  and  before  death  she  became  partially 
comatose. 

On  inspection  there  were  adhesions  between  the  liver,  colon,  and  stomach, 
and  the  peritoneum  contained  about  a  gallon  of  serum.  The  liver  was  in  a 
state  of  advanced  cirrhosis.  The  stomach  was  moderate  in  size,  flaccid,  and 
on  the  inner  aspect  of  its  anterior  wall  presented  a  large  villous  growth,  about 
three  inches  in  diameter,  the  edges  of  which  were  raised,  and  the  centre 
ulcerated.  On  floating  in  water,  it  presented  beautiful  villous  processes ; 
these,  under  the  microscope,  were  found  to  consist  of  long,  delicate  growths, 
some  terminating  in  points,  and  filled  with  granules.  The  base  of  the  growth 
presented  nuclei.  There  was  no  hypertrophy  of  the  pylorus,  nor  of  any  por- 
tion of  the  muscular  coat.  The  other  portions  of  the  mucous  membrane 
presented  gastric  follicles,  containing  fat  and  nuclei.  The  kidneys  were 
atrophied. 

In  this  case,  with  the  exception  of  burning  at  the  stomach  two 
months  before  death,  which  is  not  an  unfrequent  symptom  of  dys- 
pepsia, there  was  no  sign  observed  of  disease  of  the  stomach.  This 
is  partly  explained  by  the  disease  affecting  the  anterior  surface  of 
the  organ,  leaving  the  pylorus  perfectly  free.  This  absence  of  ob- 
struction was  further  shown  by  the  atrophic  rather  than  hypertro- 
phic  condition  of  the  muscular  coat.  The  advanced  disease  of  the 
liver,  producing  dropsy,  appeared  sufficient  to  explain  all  the  symp- 
toms, and  the  distension  of  the  stomach  entirely  prevented  any 
tumor  being  felt  at  that  region.  The  appearance  of  the  growth, 
under  the  microscope,  gave  less  positive  proof  of  a  cancerous  origin 
than  in  the  preceding  case ;  some  granules  at  the  base  of  the  villi, 
but  none  of  the  ordinary  cancer-cells  or  nuclei,  were  present. 

CASE  LXXI.  Colloid  Cancer  of  the  Stomach  and  of  the  Colon — Eliza- 
beth T— ,  jet.  37,  had  been  a  servant,  and  had  been  out  of  health  for  four 
months,  but  twelve  months  previous  to  admission  she  had  had  jaundice.  She 
was  somewhat  emaciated,  and  had  a  sallow,  aged,  and  very  haggard  expres- 
sion of  countenance.  She  complained  much  of  flatulent  distension  of  the 


200  ORGANIC    DISEASES    OF    THE    STOMACH. 

abdomen,  with  a  sensation  of  sinking  at  the  scrobiculus  cordis  ;  after  eating 
she  suffered  much  pain  at  the  stomach,  but  the  pain  was  most  severe  after 
taking  fluids.  There  was  occasional  vomiting,  or  rather  regurgitation  of  thin, 
glairy,  and  gelatinous  fluid;  this  fluid  came  up  into  the  throat,  especially  at 
night.  The  bowels  were  constipated,  and  she  was  troubled  with  hemorrhoids. 
The  abdomen  was  moderately  distended,  but  no  tumor  could  be  felt  on  manipu- 
lation. The  pulse  was  feeble.  She  was  in  a  semi-jaundiced  and  drowsy 
condition,  complained  of  a  sense  of  fulness  in  the  head,  and  of  muscoe  voli- 
tantes ;  she  became  more  and  more  exhausted,  and  gradually  sank  in  about 
a  month. 

Inspection — The  body  was  not  extremely  emaciated.  The  intestines  were 
much  distended  with  flatus,  and  the  peritoneal  sac  contained  several  pints  of 
fluid.  The  stomach  was  very  much  contracted,  and  its  walls  were  three- 
fourths  of  an  inch  in  thickness.  The  outer  or  muscular  layer  was  a  quarter 
of  an  inch  in  thickness,  semi-transparent,  and  it  was  divided  by  white  bands 
which  were  continuous  with  the  submucous  tissue.  The  mucous  membrane 
had  a  pulpy,  honeycomb  appearance,  and  it  was  replaced  by  minute  colloid 
cysts,  containing  clear,  gelatinous  fluid ;  these  cysts  were  most  distinctly  ob- 
se.-ved  on  the  internal  surface  of  the  stomach  ;  there  were  also  some  ulcera- 
tion  and  congestion  of  the  vessels.  The  pylorus  was  not  thicker  than  the 
rest  of  the  stomach  ;  but  the  hypertrophy  of  the  muscular  coat  extended  the 
whole  length  of  the  oesophagus.  Some  of  the  glands  of  the  curvature  of  the 
stomach  were  hard  and  thickened.  The  fluid  from  the  colloid  cysts  contained 
large  cells  filled  with  several  nuclei,  and  were  surrounded  by  very  delicate 
stroma.  The  vessels  of  the  stomach  were  rendered  quite  patulous  by  the 
tissues  placed  around  them.  The  small  intestines  were  free,  but  the  large 
intestine  was  much  thickened ;  immediately  above  the  ca3cum  there  was  a 
portion  of  colon  affected  with  colloid  growth,  and  from  the  hypertrophy  of 
the  muscular  coat  it  had  the  appearance  of  a  pyloric  valve ;  the  submucous 
coat  also  was  much  thickened.  Some  of  the  solitary  glands  in  the  colon 
were  enlarged.  The  liver,  kidneys,  and  spleen  were  healthy ;  so  also  the 
thoracic  viscera.  The  heart  was  contracted. 

In  this  case  the  symptoms  at  first  were  not  all  more  severe  than 
those  often  observed  in  pyrosis,  with  flatulent  distension  of  the  nl>- 
domen;  nor  was  the  serious  nature  of  the  disease  for  some  time 
anticipated. 

The  stomach  is  preserved  in  the  Museum,  No.  181329,  and  shows 
in  a  very  beautiful  manner  the  structure  of  colloid  cancer.  The 
hypertrophy  of  the  muscular  coat  was  remarkably  extensive,  reach- 
ing into  and  passing  along  the  whole  length  of  the  oesophagus.  The 
small  intestine  was  free ;  but  the  mucous  membrane  of  the  colon  was 
affected  with  similar  disease  to  that  of  the  stomach.  Of  this  there 
was  no  evidence  during  life,  although  the  constipation  of  the  bowels 
was,  perhaps,  rather  more  obstinate  than  in  cases  of  ordinary  cancer 
of  the  stomach,  but  not  more  than  is  observed  in  many  cases  of  dys- 
pepsia. The  most  marked  symptom  was  the  regurgitation,  and  the 
filling  of  the  mouth  during  sleep  with  watery,  gelatinous  fluid  ;  this 
unfortunately,  was  not  examined  microscopically  during  life ;  it  might 
have  afforded  clear  evidence  of  the  nature  of  the  disease.  The  seiui- 
jaundiced  condition  arose  from  slight  pressure  by  diseased  glands  on 
the  common  bile-duct,  and  the  colloid  growth  gradually  extended 


ORGANIC    DISEASES    OF    THE    STOMACH.  201 

through  the  whole  of  the  mucous  membrane  of  the  stomach  by  con- 
tinuity of  structure. 

CASE  LXXII.  Colloid  Cancer  of  the  Stomach,  the  Omentum,  the  Peri- 
toneum, and  of  the  Rectum — John  C — ,  set.  47,  was  a  pensioner,  and  one 
month  before  his  admission  began  to  experience  pain  at  the  scrobiculus  cor- 
dis.  Vomiting  came  on,  with  costiveness  and  gradual  emaciation.  A  tumor 
could  be  felt  extending  across  the  abdomen,  and  it  was  doubtful  whether  this 
was  the  margin  of  the  liver,  or  a  tumor  involving  the  pylorus,  or  merely 
thickened  omentum. 

The  parietes  of  the  abdomen  were  very  thin.  The  peritoneal  cavity  con- 
tained several  gallons  of  fluid,  of  very  deep  color,  almost  sanguineous;  the 
serum  presented  shreds  of  lymph,  and  other  delicate  bands  of  lymph  passed 
between  the  coils  of  the  intestine.  The  omentum  was  found  to  be  contracted 
into  a  thick,  yellowish  mass,  about  half  an  inch  in  breadth,  which  projected 
towards  the  abdominal  parietes.  The  margin  was  irregularly  notched,  and 
situated  immediately  above  the  transverse  colon.  The  surface  of  the  liver 
was  roughened  by  small  gelatinous  tubercles,  and  a  thick  layer  covered  the 
whole  opposed  surface  of  the  diaphragm,  which  at  this  part  was  much  thick- 
ened, and  the  pleural  surface  was  also  encroached  upon.  The  lesser  omen- 
tum was  also  much  thickened,  and  a  white,  hard  mass,  about  the  size  of  a 
hen's  egg,  was  situated  at  the  lesser  curvature  of  the  stomach,  near  the  py- 
lorus. The  small  intestines  were  contracted,  the  large  were  distended ;  the 
peritoneal  surface  was  everywhere  studded  with  small  tubercles,  from  the  size 
of  a  millet-seed  to  that  of  a  bean  ;  these  were  soft,  gelatinous,  and  of  a  red 
color.  The  sac  of  the  lesser  omentum  contained  tubercles  similar  to  those  in 
the  general  cavity  of  the  peritoneum,  and  it  was  distended  with  fluid.  The 
cavity  of  the  stomach  was  small,  its  parietes  were  thickened,  and  at  the  lesser 
curvature  from  the  oesophagus  to  the  pylorus  the  mucous  membrane  was 
irregularly  raised,  and  presented  an  appearance  of  cells  distended  with  clear, 
gelatinous  fluid.  The  larger  curvature  was  healthy  ;  the  liver  was  small,  and 
of  a  deep  bilious  color;  the  hepatic  cells  contained  very  little  fat.  The  pan- 
creas and  the  small  and  large  intestines  were  healthy,  but  at  the  commence- 
ment of  the  rectum  was  a  small  nodule  of  cancerous  growth  ;  this  had  led  to 
the  thickening  of  the  mucous  and  muscular  coat,  and  the  intestine  at  that 
part  would  scarcely  admit  the  index  finger.  Preparation  No.  181 330. 

The  microscopical  examination  showed  the  well-marked  characters 
of  colloid  cancer.  The  growths  on  the  peritoneum  consisted  of  large, 
poly-nucleated  cells,  with  delicate  intervening  stroma.  In  the  omen- 
turn  there  was  a  greater  quantity  of  fibrous  tissue  between  the  ceils; 
and  some  of  the  cells  contained  four  or  five  large  nuclei,  which  Avere 
rendered  very  distinct  by  acetic  acid.  The  mucous  membrane  of  the 
stomach  presented  similar  structural  elements.  The  affection  of  the 
rectum  in  this  case  was  an  interesting  association  of  disease. 

CASE  LXXIII.  Chronic  Ulceration  of  the  Stomach.  Cancer — James 
T— ,  ret.  4G,  a  weaver,  who  had  been  living  at  Spitalfields,  was  a  regular  and 
sober  man,  but  he  had  been  a  great  smoker.  His  father  and  mother  both 
died  of  phthisis  ;  for  thirty-four  years  he  had  been  employed  at  the  loom,  and 
he  had  suffered  much  from  the  shuttle  striking  the  scrobiculus  cordis ;  these 
blows  at  first  produced  nausea  and  faintness,  which  continued  for  several 
hours.  Five  years  before  admission  the  same  unpleasant  symptoms  returned, 
obliging  him  to  discontinue  his  work  ;  they  were  accompanied  with  vomiting, 


202  ORGANIC    DISEASES    OF    THE    STOMACH. 

although  at  first  only  his  breakfast  was  rejected  ;  these  symptoms  continued 
for  four  years,  and  then  left  him  for  three  months,  during  which  time  he 
rapidly  gained  flesh,  and  continued  his  employment. 

Six  months  prior  to  his  appearance  at  Guy's  he  was  again  attacked  with 
pain  and  vomiting,  and  he  began  to  lose  flesh  ;  he  suffered  great  pain  if  -he 
fasted,  but  on  taking  food  the  pain  very  soon  returned,  and  it  was  only  re- 
lieved by  vomiting  ;  the  vomiting  sometimes  came  on  immediately  arter  a 
meal,  or  it  was  delayed  for  about  six  hours  ;  he  had  never  vomited  blood  ; 
the  bowels  were  constipated,  and  the  urine  scanty. 

He  was  a  small  man,  of  light  complexion,  and  had  a  diabetic  appearance. 
The  chest  was  healthy ;  the  tongue  was  moist  and  clean ;  the  abdomen  soft, 
flattened,  and  contracted  ;  the  integuments  dry.  Fluid  magnesia  5>s,  and 
dilute  hydrocyanic  acid  n^iij,  were  ordered  three  times  a  day  ;  and  a  soap 
enema. 

The  vomiting  continued  very  severe,  and  he  became  increasingly  prostrate ; 
hiccough  came  on,  coffee-ground  vomiting,  and  he  gradually  sank. 

On  inspection,  the  body  was  extremely  emaciated ;  the  lungs  were  col- 
lapsed :  much  black  pigment  was  found  upon  them,  but  they  were  otherwise 
healthy.  The  heart  was  healthy.  Abdomen — The  intestines  were  collapsed. 
At  the  duodenum  there  was  much  contraction  from  puckering  of  the  omentum 
and  stomach.  Stomach — The  walls  were  exceedingly  thin  and  atrophied ; 
about  two  inches  from  the  pylorus  was  a  contraction,  which  at  first  was  mis- 
taken for  the  pylorus  ;  there  was  considerable  contraction  also  of  the  omentum 
at  that  part,  and  firm  semi-cartilaginous  hardness  of  the  structure.  On  open- 
ing the  stomach,  an  oval  ulcer,  about  two  and  a  half  inches  in  length,  and 
one  in  breadth,  was  observed  surrounding  the  constriction  ;  its  edges  were 
rounded  and  elevated ;  its  base  quite  smooth.  On  section,  the  mucous  mem- 
brane appeared  to  be  continuous  with  the  upper  layer  of  the  ulcer  ;  its  deeper 
layers  were  very  firm,  white,  and  fibrous.  Beyond  the  ulcer  and  its  contrac- 
tion was  a  portion  of  healthy  mucous  membrane,  then  the  pylorus,  which  was 
also  perfectly  healthy.  The  first  part  of  the  duodenum  was  congested,  and 
there  was  pigment  in  the  mucous  membrane.  In  the  omentum  were  several 
hard  tumors,  and  the  omentum  itself  formed  a  firm  contracted  mass,  about 
the  size  of  the  middle  finger.  On  section  these  structures  were  firm,  and 
contained  whitish  juice,  and  under  the  microscope  showed  large  cells  contain- 
ing large,  very  distinct  nuclei,  evidently  cancerous.  In  the  stomach  no 
follicles  could  be  detected  on  the  smooth  surface  of  the  ulcer ;  and  in  the 
structures  beneath,  none  of  the  cancerous  cells  found  in  the  omentum  and 
glands  were  present,  but  abundant  fibrous  tissue  ;  there  was  also  much  fibrous 
tissue  in  the  omentum,  &c.  The  rest  of  the  intestine  was  healthy  ;  the  colon 
was  contracted,  and  contained  some  scybala.  The  liver  was  healthy  ;  the 
spleen  was  enlarged  and  firm  ;  the  kidneys  also  were  healthy. 

The  history  and  appearances  after  death  in  this  case  warranted 
the  belief  that  ulceration  of  the  stomach  had  existed  for  a  considerable 
time ;  and  although  we  found  evidence  of  cancerous  tubercles  in  the 
omentum,  I  think  it  probable  that  the  development  of  cancerous 
growth  only  took  place  during  the  latter  stage  of  the  disease ;  the 
growth  closely  resembled  chronic  ulcer  in  its  general  and  microsco- 
pical appearance,  except  that  it  nearly  surrounded  the  pyloric  ex- 
tremity. In  some  instances,  cancerous  deposit  takes  place  at  the 
edges  of  a  chronic  ulcer :  such,  however,  was  not  the  case  here.  This 
case  corresponds  with  those  previously  referred  to,  in  which  a  can- 


ORGANIC    DISEASES    OF    THE    STOMACH.  203 

cerous  action  took  place  in  the  glands  and  structures  adjoining  the 
chronic  irritation. 

CASE  LXXIV.     Cancer  of  the  Stomach.     Communication  with  the  Colon. 

Ulceration  of  the  Caecum  and  lleum.     Chronic  Phthisis John  T ,  set.  67, 

was  admitted  August  15,  1855  ;  he  was  a  married  man,  who  had  resided  at 
Greenwich.  He  had  been  out  of  health  for  twelve  months,  complaining  of 
dyspepsia,  and  pain  at  the  scrobiculus  cordis ;  the  food  appeared  to  remain  at 
the  end  of  the  oesophagus,  and  not  to  reach  the  stomach.  There  had  been 
no  vomiting  either  before  or  after  admission,  but  a  hard  defined  growth  could 
be  felt  at  the  scrobiculus  cordis,  which  left  no  doubt  as  to  the  nature  of  the 
complaint;  the  abdomen  was  collapsed.  On  September  15th  he  was  greatly 
emaciated  and  able  to  take  but  very  little  food  ;  his  mind  wandered  *much  ; 
the  feet  and  hands  were  cedematous  ;  and  numerous  spots  of  purpura  were 
found  on  the  hands  and  forearms.  He  gradually  sank. 

Inspection — The  body  was  much  emaciated.  Chest Very  strong  pleu- 
ritic adhesions  were  found,  especially  at  the  right  apex ;  the  right  lung  was 
puckered,  exceedingly  dense,  and  on  section  presented  iron-gray  consolida- 
tion, occupying  nearly  the  whole  upper  lobe ;  in  the  centre  it  was  firm  and 
calcareous  ;  the  lower  portion  of  the  upper  lobe  contained  numerous  miliary 
tubercles,  some  surrounded  by  dense,  others  with  crepitant  lung;  in  the 
lower  lobe  were  scattered  isolated  miliary  tubercles,  semi-transparent  in 
color.  On  the  surface  of  the  lobe  were  several  lobules,  which  were  broken 
down  in  the  centre  into  thin  pus,  and  surrounded  by  a  tolerably  defined 
margin  ,  the  extreme  edge  of  the  lung  was  emphysematous  ;  the  left  lung  was 
in  a  similar  condition,  but  the  bronchial  glands  were  healthy.  The  tubercles 
in  the  lungs  consisted  of  molecular  matter,  of  small  irregular  cells  and  nuclei ; 
some  of  the  cells  were  the  size  of  the  ordinary  ones  in  the  pulmonary  struc- 
ture, but  none  were  like  those  in  the  stomach. 

The  abdomen  was  collapsed;  the  stomach  was  firmly  adherent  to  the  trans- 
verse colon.  On  opening  the  former,  along  the  lesser  curvature,  a  large 
growth,  nearly  four  inches  in  circumference,  was  found  at  the  pyloric  ex- 
tremity, involving  the  whole  of  the  pylorus,  and  surrounding  the  stomach  at 
that  part ;  the  edge  was  thick,  rounded,  and  raised  an  inch  above  the  sur- 
rounding mucous  membrane,  so  that  the  growth  formed  a  sort  of  cup ;  the 
margin  was  of  a  deep  purplish  hue ;  the  centre  presented  an  irregular  ragged 
slough  of  a  brown  color;  it  was  deeply  excavated,  and  had  a  feculent  odor. 
At  the  pylorus  the  muscular  coat  was  about  four  inches  in  thickness,  of  a 
whitish  color,  with  small  intersecting  semi-transparent  bands.  Nearer  to  the 
cardiac  extremity  were  two  small  raised  growths,  one  about  half  an  inch  in 
diameter,  red  and  prominent ;  the  other  about  a  quarter  of  an  inch  in  dia- 
meter. The  rest  of  the  mucous  membrane  was  pale.  The  stomach  near  the 
pylorus  was  firmly  adherent  to  the  transverse  colon,  and  from  the  centre  of 
the  slough  a  probe  could  be  passed  into  the  colon ;  the  opening  in  the  colon 
was  valvular,  gray,  and  about  a  line  in  diameter.  The  pancreas  and  omentum 
were  healthy ;  several  mesenteric  glands  in  the  neighborhood  were  infiltrated 
witli  soft  cancerous  product.  The  duodenum  was  gray,  but  its  mucous  mem- 
brane healthy ;  at  the  ilio-caecal  valves  were  the  remains  of  an  ulcer  occupy- 
ing nearly  the  whole  of  the  last  Fever's  gland,  and  extending  to  the  caicum ; 
its  margin  was  raised,  and  presented  several  congested  nodules.  Externally 
the  cellular  coat  was  firm,  hard,  and  contracted.  The  remaining  part  of  the 
intestines  was  healthy. 

On  examining  the  surface  with  the  microscope,  the  growth  presented  on 
the  surface  columnar  epithelium,  and  consisted  of  nucleated  cells,  with  very 


204  ORGANIC    DISEASES    OF    THE    STOMACH. 

large  and  distinct  single  or  double  nuclei,  and  of  delicate  intervening  fibrous 
tissue;  there  was  no  doubt  of  their  cancerous  character.  The  adjoining 
mucous  membrane  presented  numerous  fat  particles  in  the  follicles;  the  glands 
contained  similar  cancerous  nuclei.  The  ulcer  in  the  ileum  and  ca-cuni  ap- 
peared partly  cicatrized ;  it  did  not  present  any  cancerous  product,  but  only 
fibrous  tissue.  At  the  pylorus,  bands  of  involuntary  muscular  fibre  were 
found  to  extend  between  the  cancerous  elements. 

As  far  as  could  be  decided  by  microscopical  examination,  the 
disease  in  the  lung  was  of  a  non-cancerous  character;  it  appeared  to 
consist  in  a  chronic  and  almost  quiescent  state  of  phthisis ;  but  besides 
this  chronic  disease,  there  was  evidence  of  acute  lobular  pneumonia, 
which  had  probably  come  on  a  short  time  before  death.  The  condi- 
tion of  the  ileum  was  that  of  a  healing  ulcer.  It  was  difficult  to 
obtain  a  full  history  from  the  patient,  and  the  evident  cancer  of  the 
stomach  obscured  the  signs  of  pulmonary  disease.  The  existence  of 
a  communication  with  the  colon  was  not  known  during  life. 

CASE  LXXV.  Struma.  Cancer  of  the  Stomach — Hannah  W — ,  jet.  33, 
was  admitted  October,  1857.  She  was  a  thin,  emaciated  young  woman,  pale, 
with  a  dejected  and  somewhat  melancholic  expression;  she  had  always  bei-n 
delicate,  and  had  been  subject  for  a  long  time  to  vomiting.  For  twelve 
months  she  had  suffered  constantly  from  this  symptom,  which  generally  came 
on  in  the  evening;  menstruation  had  also  ceased  during  that  period;  but 
there  was  no  evidence  of  disease  of  the  ovary.  January,  1858 — The  abdo- 
men was  moderately  rounded,  and  there  was  considerable  tenderness  at  the 
scrobiculus  cordis ;  and  at  the  region  of  the  greater  curvature  towards  the 
pylorus,  a  large  tumor  or  induration  could  be  felt.  At  the  angle  of  the  jaw, 
on  the  left  side,  there  was  enlargement  of  the  glands  of  the  neck;  no  disease 
could  be  detected  in  the  chest,  but  the  respiration  was  very  coarse  at  the 
apices.  The  heart  was  normal.  Various  remedies,  had  been  tried  to  relieve 
the  irritability  of  the  stomach,  and  magnesia  mixture,  creasote,  calomel,  &c., 
had  been  given.  Steel  pill  and  some  lemon-juice  were  occasionally  taken, 
but  afforded  only  slight  and  temporary  relief.  Bismuth,  and  afterwards  tin- 
injection  of  nutrient  enemata,  were  then  tried,  but  without  relief;  solid  food 
produced  excessive  pain,  and  fluids  had  the  same  effect,  although  in  less 
degree.  February  1st — She  was  unable  to  bear  the  injections,  and  com- 
plained much  of  pain.  The  tumor  was  more  distinct,  oblong,  hard,  and 
tender;  the  pulse  compressible,  the  face  flushed.  One  drachm  of  fluid  pepsine 
with  mucilage  was  tried,  with  a  small  quantity  of  chop,  and  milk  diet  night 
and  morning.  4th — She  was  rather  more  comfortable.  Gth — She  com- 
plained of  nausea  after  the  medicine.  Opium,  1  grain,  was  given  every  night. 
April  8th — Continued  in  the  same  anaemic  condition,  but  the  emaciation 
became  greater;  the  abdomen  was  collapsed;  the  tumor  in  the  lower  part  of 
the  epigastric  region  was  distinct,  but  not  enlarged;  and  there  was  greater 
prostration.  The  pain  and  vomiting  remained  as  before.  She  gradually 
sank,  and  died  July  9th,  1858. 

Inspection  nine  hours  after  death.— There  was  consolidation  of  the  lower 
lobe  of  the  left  lung.  The  bronchial  glands  were  enlarged  and  filled  with 
firm  and  cheesy  deposit.  The  glands  on  the  left  side  of  the  neck  were  en- 
larged from  strumous  deposit.  The  heart  and  pericardium  were  healthy. 
The  peritoneum  was  healthy.  The  stomach  was  reduced  in  size;  the  walls 
were  infiltrated  with  cancer,  extending  from  the  pylorus  to  the  oesophagus, 
along  the  lesser  curvature,  and,  in  some  parts,  were  three-quarters  of  an  inch 


ORGANIC    DISEASES    OF    THE    STOMACH.  205 

in  thickness,  whitish,  firm,  and  consisting  of  cancerous  cellular  deposit.  The 
muscular  coat  was  much  hypertrophied.  The  lesser  curvature  was  adherent 
to  the  pancreas,  and  the  neighboring  glands  were  infiltrated.  The  mesenteric 
glands  contained  white  softened  deposit.  The  liver  presented  vascular  nodules 
of  cancerous  deposit,  their  central  parts  being  depressed ;  some  nodules  were 
firmer,  and  white  in  color.  The  right  ovary  was  enlarged. 

In  this  case  the  association  of  strumous  disease  of  the  glands  of 
the  neck  and  of  the  chest,  with  cancerous  disease  of  the  stomach, 
was  unusual.  The  patient  was  younger  than  those  usually  affected 
with  cancer,  and  the  duration  of  the  disease,  which  lasted  two  years, 
was  greater  than  in  ordinary  cases.  The  pain  was  severe  through- 
out the  disease,  and  this  suffering  was,  perhaps,  due  to  the  infiltration 
of  the  glands  about  the  ganglia,  or  to  the  implication  of  branches  of 
the  pneumogastric  nerve  in  the  diseased  walls  of  the  stomach. 

CASE  LXXVI.  Cancer  of  the  Stomach.  Disease  of  the  Supra-renal 
Capsule — John  S — ,  set.  43,  a  sailor,  was  admitted  into  Guy's  Hospital, 
under  Dr.  Barlow's  care,  December  21st,  1859.  Six  years  before  he  had 
had  dysentery  in  the  Black  Sea.  In  November,  1859,  he  was  taken  ill  some- 
what suddenly  at  Malta,  he  fell  down  on  deck,  and  sutfered  from  severe  pain 
at  the  scrobiculus  cordis.  He  remained  in  hospital  at  Malta  for  a  month  ; 
vomiting  then  came  on,  and  afterwards  continued ;  but  he  had  occasional 
intervals  of  cessation  of  several  days'  duration.  On  admission  he  was  emaci- 
ated, and  had  a  haggard,  distressed  appearance ;  he  had  severe  pain  across 
the  abdomen.  In  January,  1860,  severe  vomiting  returned,  generally  after 
every  meal,  or  at  night ;  the  bowels  were  much  constipated  ;  he  was  prostate, 
and  on  placing  the  hand  on  the  abdomen  a  hard  growth  could  be  felt  in  the 
region  of  the  pylorus  and  gall-bladder.  The  forehead  was  discolored,  as  in 
Melasma  Addisonii.  He  slowly  sank,  and  died  February,  1860.  There  was 
an  inspection  on  the  20th,  and  a  cancerous  ulcer,  about  three  inches  in  diam- 
eter, was  found  at  the  pylorus  ;  its  edges  were  slightly  raised,  and  its  surface 
sloughy ;  near  to  the  liver  was  some  infiltration  of  medullary  matter.  The 
supra-renal  capsules  were  enlarged  and  infiltrated.  No  other  part  was  dis- 
eased. 

The  symptoms  in  this  case  were  marked,  but  the  sadden  onset  of 
the  disease,  causing  him  to  fall  whilst  walking  and  carrying  a  tray 
on  deck,  was  unusual,  and  might  have  led  to  an  incorrect  diagnosis. 
The  patient  rapidly  became  very  prostrate,  and  it  is  probable  that  the 
affection  of  the  supra-renal  capsules  tended  to  increase  the  exhaus- 
tion, and  hastened  the  fatal  termination. 

CASE  LXXVII.  Cancer  at  the  Pylorus,  simulating  Disease  of  the  (Eso- 
phagus. Communication  with  the  Colon — James  E — ,  set.  61,  was  under 
my  care  in  Guy's  Hospital  in  1859.  He  was  a  hawker,  who  had  resided  at 
Kensington  ;  his  habits  of  life  had  been  intemperate.  He  had  been  in  St. 
George's  Hospital  with  fractured  ribs ;  hajmoptysis  followed,  and  from  1852 
he  had  suffered  from  bronchitis.  In  1857  he  was  in  the  Consumption  Hos- 
pital for  bronchitis;  but  at  the  same  time  he  had  dyspepsia,  with  occasional 
nausea.  In  October,  1858,  he  first  noticed  a  small  hard  swelling  in  the  left 
'hypochondriac  region  ;  it  was  movable,  and  did  not  cause  any  pain.  After 
that  time  he  gradually  emaciated,  and  had  daily  increase  of  pain  at  the 
affected  part ;  and  vomiting,  previously  occasional,  became  almost  constant, 


206  ORGANIC    DISEASES    OF    THE    STOMACH. 

although  it  sometimes  ceased  for  several  days.  On  admission,  on  March  19th, 
he  had  a  sallow,  slightly  jaundiced,  appearance  ;  he  was  of  dark  complexion  ; 
his  skin  was  of  normal  temperature  ;  the  tongue  was  furred,  and  brown  in 
the  centre,  but  whitish  at  the  edges.  The  chest  presented  the  signs  of  old 
bronchitis  ;  the  heart-sounds  were  normal,  but  the  pulse  was  feeble,  75.  The 
abdomen  was  tense  and  resisting,  and  was  resonant,  excepting  at  the  epigas- 
tric and  left  hypochondriac  regions,  where  a  defined  tumor  was  present ;  the 
tumor  was  painful  on  pressure,  and  had  slight  pulsation,  and  on  taking  solids 
they  were  instantly  rejected,  as  if  there  were  obstruction  at  the  extremity  of 
the  oesophagus  ;  but  fluids  were  retained  for  three  or  four  hours,  and  were 
then  rejected  as  a  chyme-like  mass.  There  was  interscapular  pain.  The 
bowels  were  much  confined ;  the  urine  was  high  colored,  of  sp.  gr.  1020,  and 
free  from  albumen  and  sugar.  On  April  14th  he  vomited  dark  offensive 
matter,  of  almost  fecal  odor.  Local  erysipelas  of  the  forehead  and  right 
eyelid  came  on,  and  slight  abscess  followed.  This,  however,  subsided  ;  but  he 
gradually  sank,  and  died  June  19th.  The  abdomen  only  could  be  examined. 
There  was  a  tumor  at  the  pylorus,  about  the  size  of  a  closed  fist,  firmly  ad- 
herent to  the  anterior  abdominal  parietes  and  to  the  edge  of  the  liver.  On 
removing  it  from  the  parietes  a  small  abscess  was  found  to  have  been  pro- 
duced anteriorly  from  the  extension  of  the  cancer  to  the  surface,  and  the  con- 
sequent local  peritoneal  inflammation.  On  opening  the  stomach,  the  pyloric 
end  was  found  to  be  occupied  by  a  large  cancerous  growth,  which  extended 
about  three  inches  into  the  stomach  and  surrounded  the  orifice,  and  it  reached 
nearly  to  the  oesophageal  opening  at  the  lesser  curvature.  The  growth  was 
sprouting  and  fungating ;  it  had  a  green,  sloughy  appearance,  and  was  situ- 
ated in  the  mucous  and  submucous  tissues.  Posteriorly  the  muscular  coat 
was  hypertrophied,  but  anteriorly  this  coat  was  invaded  by  the  cancerous 
disease,  and  there  was  adhesion  to  the  anterior  abdominal  parietes.  There 
was  adhesion  also  with  the  colon,  and  a  communication  existed,  through 
which  a  probe  could  be  passed.  The  pancreatic  glands  were  involved,  but 
the  other  abdominal  viscera  were  healthy.  The  growth  was  soft,  vascular, 
and  of  an  encephaloid  character. 

Tbe  vomiting,  in  this  instance,  during  the  early  stage  of  the  dis- 
ease, took  place  so  quickly  after  deglutition,  that  the  disease  was  at 
first  referred  to  the  oesophagus,  and,  till  nearly  the  close  of  life,  the 
cardiac  extremity  rather  than  the  pylorus  was  supposed  to  be  the 
seat  of  organic  mischief.  The  communication  with  the  colon  gave 
a  fecal  odor  to  the  ejected  matters,  and  the  extension  of  disease  to 
the  skin  would,  in  a  few  days,  if  life  had  been  prolonged,  have  led 
to  the  formation  of  an  artificial  anus. 

CASE  LXXVIII.  Cancer  of  the  Pylorus.  Hydatid  Disease  of  the  Cellular 
Tissue  of  the  Bladder. — W.  A — ,  set.  52,  a  clerk,  who  had  resided  at  Wool- 
wich, was  admitted  into  Guy's  Hospital  under  my  care,  March  28th,  1HGO. 
He  had  enjoyed  good  health  till  eight  months  previously,  when  loss  of  appe- 
tite and  vomiting  after  food  came  on  ;  the  rejection  of  food  took  place  either 
at  once  or  after  long  intervals.  The  bowels  were  constipated.  Emaciation 
had  gradually  become  extreme,  and  when  brought  to  the  hospital  it  was 
thought  that  he  would  scarcely  reach  the  ward.  He,  however,  rallied,  and 
survived  for  three  weeks.  Vomiting  did  not  recur  till  two  days  before  death. 
There  were  no  signs  of  disease  of  the  chest.  The  abdomen  was  much  con- 
tracted;  an  ill-defined  tumor  could  be  felt  in  the  region  of  the  pylorus;  and 
there  appeared  to  be  no  doubt  that  he  suffered  from  chronic  disease  of  the 


ORGANIC    DISEASES    OF    THE    STOMACH.  207 

stomach.  He  had  not  suffered  from  htemetamesis,  neither  did  he  complain 
of  any  pain  at  the  stomach.  The  diagnosis  of  cancerous  disease  was  confirmed 
at  the  inspection.  In  the  hypogastric  region  was  a  tumor  reaching  as  high 
as  the  umbilicus,  precisely  resembling  in  form  a  distended  urinary  bladder ; 
it  was  dull  on  percussion,  rounded  in  form,  and  fluctuation  was  distinct ;  it 
was  also  readily  felt  in  the  rectum.  The  patient  stated  that  he  never  experi- 
enced any  difficulty  in  passing  water,  nor  had  he  any  pain  at  the  part.  A 
catheter  was  passed  without  difficulty,  and  a  few  ounces  of  healthy  urine 
were  drawn  off.  On  inspection  the  thoracic  viscera  were  found  to  be  in  a 
healthy  state ;  the  peritoneum  also  was  healthy.  The  stomach  was  slightly 
distended,  and  on  drawing  it  aside,  a  marked  constriction  was  observed  at 
the  pylorus ;  and  several  of  the  glands  at  the  lesser  omentum  and  near  the 
pancreas  were  enlarged  and  infiltrated  with  cancerous  product.  A  firm 
growth  was  found  to  exist  at  the  pylorus,  extending  into  the  stomach  for 
about  one  inch  and  a  half,  where  it  terminated  by  a  rounded,  raised,  and 
vascular  edge ;  the  valve  was  quite  surrounded  by  the  growth,  and  the  sur- 
face was  partially  ulcerated.  The  growth  had  a  similar  vascular  and  raised 
edge  on  the  duodenal  aspect,  but  was  there  less  prominent.  The  little  finger 
could  be  passed  through  the  pylorus.  The  growth  was  of  a  yellowish-gray 
color,  moderately  firm,  containing  succulent  fluid :  it  was  composed  of  cells 
with  large  nuclei,  free  nuclei,  elongated  cells,  &c.,  and  was  evidently  cancer- 
ous. The  liver,  kidneys,  and  spleen,  were  healthy,  so  also  the  intestine. 
The  ureters  were  not  distended,  the  right  one  was  spread  out  on  the  cyst, 
which  occupied  the  usual  position  of  the  bladder;  whilst  the  bladder  was 
itself  flaccid  and  situated  on  the  left  side  of  the  hypogastric  tumor.  The 
peritoneum  was  smooth  and  healthy.  The  mucous  membrane  of  the  bladder, 
the  prostate  and  urethra,  the  vesiculse  seminales,  and  vasa  deferentia,  were 
all  normal.  To  the  right  of  the  bladder,  in  the  median  line,  and  apparently 
developed  in  the  loose  cellular  tissue  of  the  bladder,  was  a  large  hydatid  cyst, 
holding  nearly  three  pints  of  small  cysts,  varying  in  size  from  a  line  to  an 
inch  in  diameter,  and  full  of  clear  fluid.  At  the  base  of  the  cyst  was  a  firm, 
yellowish-gray  substance,  containing  plates  of  cholesterine.  The  cysts  beau- 
tifully showed  their  lineated  structure,  and  numerous  booklets  of  the  echino- 
coccus  were  observed.  The  cyst  had  apparently  commenced  in  the  neighbor- 
hood of  the  prostate. 

The  diagnosis  of  cancerous  disease  at  the  pylorus  in  this  case  was 
made  out  without  difficulty  ;  but  there  was  much  obscurity  as  to  the 
character  of  the  hypogastric  cyst.  There  was  no  difficulty  in  mictu- 
rition, and  the  patient  was  scarcely  aware  of  the  presence  of  the 
tumor.  In  some  instances  the  ureters  are  compressed.  This  is 
shown  in  one  of  the  instances  recorded  by  Dr.  Bright;  the  pelves  of 
the  kidneys  became  distended,  and  suppuration  took  place  in  them ; 
in  that  case  some  of  the  hydatids  were  discharged  with  the  urine. 
Occasionally  the  pressure  is  upon  the  urethra,  when  the  cyst  may 
still  more  easily  be  confounded  with  a  distended  urinary  bladder. 
The  vomiting  in  this  case  subsided  to  an  unusual  extent,  ceasing  for 
a  fortnight. 

The  preceding  cases  indicate  several  important  facts  in  relation  to 
the  symptoms  and  course  of  cancer  of  the  stomach: — 1st.  That  the 
symptoms  may  be  exceedingly  slight,  and  the  disease  easily  over- 
looked. 2d.  That  the  indications  are  more  marked  when  the  orifices 
are  affected.  3d.  That  the  cachexia,  the  pain,  the  vomiting,  &c.,  vary 


208  ORGANIC    DISEASES    OF    THE    STOMACH. 

in  almost  every  case,  being  sometimes  slight,  or  altogether  absent; 
in  other  cases  intensely  severe,  -ith.  That  the  onset  of  the  severer 
symptoms  may  be  very  sudden,  but  it  is  generally  preceded  l>v  a 
period  of  dyspeptic  symptoms.  5th.  That  the  disease  is  not  limited 
to  persons  in  advanced  life.  6th.  That  it  is  sometimes  associated 
with  struma.  7th.  That  the  occurrence  of  cancer  with  chronic  ulcer 
of  the  stomach  tends  to  explain  some  cases  in  which  the  disease  ex- 
tends over  many  years.  8th.  That  cancerous  disease  generally  ter- 
minates within  a  year  after  a  tumor  has  formed.  9th.  That  the 
mode  of  termination  is  greatly  modified  by  the  extension  of  disease 
to  adjoining  structures.  10th.  That  in  most  cases  death  takes  place 
from  exhaustion  or  asthenia,  and  that  fatal  hemorrhage  and  peritoneal 
perforation  are  more  rare  than  in  ulceration  of  the  stomach,  llth. 
That  the  absorption  of  degenerating  cancer-structure  sometimes  leads 
to  symptoms  resembling  pyaemia.  12th.  That  some  of  the  distressing 
symptoms  may  be  alleviated,  but  that  over-active  treatment  appears 
to  hasten  the  fatal  termination. 

Although  in  several  instances  which  we  have  recorded  strumous 
disease  was  coincident  with  cancer,  the  former  appeared  to  be  in  a 
quiescent  state,  and  the  two  morbid  processes  were  not,  therefore,  in 
active  operation  together.  Still  there  may  be  some  unrevealed  con- 
nection between  these  morbid  states;  for  the  phthisical  parents  have 
children  who  die  from  cancer,  and  some  who  are  apparently  strumous 
in  early  life  are  affected  at  a  later  period  with  cancerous  disease. 
We  must  hesitate,  however,  to  consider  as  causative  and  connected, 
conditions  which  may  merely  have  coincident  relationship. 

Reference  has  been  made  to  the  presence  of  foreign  bodies  in  the 
stomach,  and  perhaps  one  of  the  most  remarkable  specimens  is  that 
which  is  preserved  in  the  Museum  of  Guy's  taken  from  an  English 
sailor,  who  had  repeatedly  swallowed  clasp  knives ;  after  several 
years  emaciation  ensued  and  death  took  place.  The  stomach  was 
found  after  death  to  contain  several  knives  and  parts  of  others,  which 
had  been  partially  dissolved. 

Stones  are  sometimes  swallowed  and  afterwards  discharged  by  the 
rectum,  and  it  is  surprising  how  foreign  bodies  may  thus  harmlessly 
pass  through  the  stomach  and  intestine  without  producing  pain  or 
any  distressing  symptom.  Coins,  nails,  in  one  instance  a  drawing- 
pin,  passed  without  pain.  Accumulations  of  hair  and  string  have 
been  found  in  the  stomach,  as  in  a  case  recorded  in  the  fourth  volume 
of  the  'Clinical  Society's  Transactions.' 


209 


CHAPTEE    VI. 

FUNCTIONAL  DISEASES  OF  THE  STOMACH. 

THE  imperfect  performance  of  the  digestive  process  constitutes 
dyspepsia ;  but,  this  general  term  is  the  expression  of  an  effect  which 
arises  from  numerous  causes,  and  it  associates  maladies  which  differ 
in  their  course,  and  in  their  termination.  Thus,  at  the  commence- 
ment and  throughout  the  course  of  organic  disease  of  the  stomach 
the  food  is  imperfectly  assimilated  ;  but  in  the  greater  number  of  in- 
stances of  gastric  disease  the  dyspepsia  is  a  transient  symptom,  and  it 
entirely  ceases  after  a  longer  or  shorter  period ;  and  where  other  dis- 
eases are  the  immediate  cause  of  death,  we  are  often  unable  to  find 
any  structural  change  in  the  stomach,  either  in  its  secretions  or 
component  parts,  although  dyspepsia  may  have  existed  for  some 
time ;  these  cases,  then,  constitute  what  are  ordinarily  regarded  as 
'functional  diseases  of  the  organ,  the  conditions  being  either  transient 
or  of  such  a  character  as  to  be  beyond  our  sphere  of  observation. 

In  the  consideration  of  functional  diseases  of  the  stomach  there 
are  some  points  which  are  essential  to  bear  in  mind,  in  order  that  we 
may  rightly  understand  the  symptoms,  and  adopt  means  for  their 
relief. 

Its  anatomical  relations.  The  diaphraym  is  situated  immediately 
above  the  stomach,  and  is  connected  to  it  at  the  oesophageal  opening; 
its  movements  affect  the  stomach,  and  are  concerned  with  the  abdomi- 
nal muscles  in  the  act  of  vomiting.  Contraction  of  the  diaphragm 
favors  the  opening  of  the  cardiac  orifice  of  the  oesophagus,  and  is 
also  the  cause  of  hiccough.  The  liver  partly  overlaps  the  stomach 
by  its  left  lobe,  and  disease  of  the  one  part  may  be  referred  to  the 
other.  The  relationship  of  the  transverse  colon  is  equally  important, 
for  not  only  does  its  distension  press  upon  the  stomach  and  interfere 
with  its  functional  activity,  but  the  omenturn,  which  is  attached  both 
to  the  stomach  and  the  colon,  may  drag  the  former  viscus  considera- 
bly downwards.  Again,  the  aorta  is  situated  behind  the  stomach 
upon  the  spine,  and  its  pulsations  are  easily  transmitted,  especially 
when  there  is  any  thickening  or  tumor  in  the  viscera  in  front.  The 
situation  of  the  stomach  corresponds  with  the  scrobiculus  cordis,  or 
the  depression  marked  out  by  the  division  of  the  ribs,  and  reaches 
downwards  in  an  ordinary  state  of  distension  to  midway  between 
'  that  part  and  the  umbilicus.  In  great  distension  it  may  occupy  the 
greater  part  of  the  abdominal  cavity  ;  it  reaches  to  the  spleen  in  the 
left  hypochondrium  beneath  the  ribs,  and  on  the  right  side  terminates 
in  the  duodenum  at  the  pyloric  orifice,  at  a  line  corresponding  to 
about  one  inch  to  two  inches  nearer  to  the  median  line  than  the  end 
of  the  ninth  rib.  Flatulent  distension  of  the  stomach  greatly  alters 
14 


210 


FUNCTIONAL    DISEASES    OF    THE    STOMACH. 


the  form  of  the  abdomen,  especially  towards  the  left  side  and  in  the 
central  portion. 

We  need  not  dwell  upon  the  physiology  of  the  stomach,  further 
than  to  remark  that  the  especial  function  of  the  stomach  is  the  solu- 
tion of  nitrogenous  food,  and  that  saccharine  and  farinaceous  food, 
as  also  oleaginous  food,  undergo  changes  and  become  absorbed  in- 
dependently of  the  action  of  the  stomach  itself.  The  conversion  of 
cane  sugar  into  grape  sugar,  and  of  farinaceous  food  into  similar 
principles,  produces  substances  which  easily  undergo  fermentation, 
and  we  have  to  bear  this  circumstance  in  mind  in  our  endeavors  to 
relieve  flatulent  distension  of  the  stomach  and  vomiting.  The  oleagi- 
nous food  becomes  emulsified  by  the  action  of  the  bile  and  pancreatic 
secretion,  prior  to  its  absorption  b}7  the  villous  processes  in  the  small 
intestine.  Absorption  takes  place  in  a  very  limited  degree  from  the 
mucous  membrane  of  the  stomach,  but  we  have  numerous  glands — 
gastric  follicles — which  secrete  an  acid  digestive  fluid.  This  fluid 
or  gastric  juice  is  strongly  acid  in  its  reaction  from  the  presence  of 
lactic  and  hydrochloric  acids,  and  it  contains  an  organic  principle — 
pepsin — which  causes  the  solution  of  the  nitrogenous  food  in  the 
diluted  acid  fluid.  Pepsin  is  closely  allied  to  albumen  and  to  fibrin. 
It  is  soluble  in  water,  but  insoluble  in  alcohol.  The  dissolved  pro- 
ducts pass  on  in  more  or  less  complete  solution,  through  the  pylorus, 
to  be  still  further  acted  upon  by  the  biliary  and  pancreatic  secretions, 
and  thereby  fitted  for  absorption  by  the  minute  villous  processes  of 
the  small  intestine. 

Schmidt  gives  the  analysis  of  the  gastric  juice  as  consisting  of— 


Water 

Pepsin 

Sugar,  albuminates,  lactic  a  id,  butyric  ac  d,  ammonia 

Chloride  of  potassium 

Chloride  of  sodium     . 

Potash 

Phosphate  of  lime 

Phosphate  of  magnesia 

Phosphate  of  iron 


954.13 

.78 

38.43 

.70 

4.26 

.17 

1.03 

.47 

.01 


Dyspepsia  or  Indigestion  is  due  to  several  causes,  and  it  may  be 
well  to  remark  upon  these  before  passing  to  the  consideration  of  the 
different  forms  of  the  disease.  Indigestion  may  be  due  to  an  im- 
proper kind  of  diet ;  the  food  may  be  unsuitable,  it  may  be  adminis- 
tered in  such  a  manner,  or  at  such  periods,  that  it  does  not  undergo 
normal  changes,  and  fermentation  instead  of  solution  is  the  result; 
or  the  apparatus  for  digestion  may,  in  one  or  other  of  its  parts,  be 
impaired,  either : — 1st.  Its  mucous  membrane  arid  its  secretion  may 
be  disordered.  2d.  The  vascular  supply  may  be  in  an  abnormal 
state.  3d.  The  nervous  system  may  be  affected.  4th.  The  muscular 
layer  may  be  so  changed  that  the  movements  of  the  stomach  are 
impeded.  Several  of  these  causes  of  dyspepsia  may  be  combined ; 
thus,  a  deficient  secretion  of  the  gastric  j  uice  may  be  due  both  to  the 
state  of  the  nervous  system,  and  also  to  the  state  of  the  capillary 
vessels,  whether  they  are  in  active  or  passive  congestion ;  some  of 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  211 

these  functional  diseases  are  very  transient  maladies,  others  pass  into 
or  are  the  commencement  of  irremediable  disease. 

It  would  lead  us  beyond  our  purpose  were  we  to  describe  the  whole 
system  of  dietary  which  is  suitable  in  health  and  disease,  neither  is 
it  necessary,  in  referring  to  each  malady  as  it  comes  before  us,  we 
allude  to  the  most  suitable  form  of  diet  in  each  case ;  but,  we  may 
remark  upon  the  importance  of  considering  the  age  of  the  patient, 
and  the  requirements  of  the  system  ;  at  a  very  early  period  of  life, 
although  digestion  is  active,  a  solid  meat  diet  is  unsuitable  and  would 
produce  serious  results,  for  the  blandest  nourishment,  such  as  milk, 
can  only  be  borne;  so  also  in  advanced  years,  the  full  diet  which  is 
an  advantage  and  necessary  during  the  vigor  of  middle  life,  and 
when  active  exercise  can  be  taken,  becomes  injurious  to  health  when 
this  activity  has  ceased.  The  period  at  which  food  is  taken  is 
scarcely  of  less  importance ;  in  early  life  it  must  be  repeated  every 
hour  or  every  second  or  third  hour;  in  middle  life  three,  four,  or 
five  hours  may  elapse  between  each  meal,  whilst,  again,  in  declining 
years  the  quantity  partaken  of  is  generally  less ;  a  smaller  interval 
of  time  should  intervene  between  the  meals,  and  it  is  often  necessary 
to  relieve  the  weakness  of  the  system  by  a  supply  of  nourishment 
during  the  night. 

In  describing  the  forms  of  dyspepsia  we  may  consider  them  as 
follows : 

1.  Those  depending  on  an  altered  condition  of  the  mucous  mem- 
brane and  of  the  gastric  juice. 

(a)  Deficiency  of  gastric  juice,  atonic  dyspepsia,  as  in  the 
dyspepsia  from  weakness,  whether  from  diseased  vessels  and 
impaired  nutrition,  from  an  exhausted  state  of  the  cerebro- spinal 
system  of  nerves,  from  exhaustion  of  the  vaso-motor  nerve. 

(/>)  Excess  of  gastric-juice. 

(c)  Irregular  secretion. 

(d)  Abnormal  composition,  as  in  pyrosis,  gout,  rheumatism, 
hepatic  disease,  albuminuria;  in  all  these  the  nervous  and  vas- 
cular systems  are  also  involved. 

2.  Dyspepsia  from  an  altered  vascular  supply,  active  and  passive 
congestion. 

3.  Dyspepsia  from  disturbance  of  the  nervous  system,  whether  the 
sympathetic  or  the  cerebro-spinal  system  of  nerves  and  especially  of 
the  pneimiogastric. 

Gastralagia. 
Excessive  irritability. 
Anorexia. 
Perverted  appetite. 

4.  Dyspepsia  from  impeded  muscular  movements ;  and 

5.  From  fermentation  of  the  contents  of  the  stomach. 

1.  Dyspepsia  arising  from  deficiency  of  the  gastric  juice  is  often 
connected  with  general  weakness  and  may  be  designated  "atonic 
dyspepsia."  Some  of  these  forms  of  disease  present  marked  and 
distinctive  symptoms,  and  for  convenience  of  description  we  may 


212  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

divide  them  (1)  into  those  connected  with  diseased  vessels  and  a 
general  failure  of  power,  as  in  advanced  life ;  (2)  exhaustion  of  the 
cerebro-spinal  system  of  nerves;  and  (3)  exhaustion  of  the  sympathetic 
or  vaso-motor  nerve.  In  advanced  life  the  glands  are  less  active  to 
secrete  gastric  juice,  the  vessels  are  less  elastic,  and  in  their  degene- 
rated state  the  circulation  becomes  feeble,  and  the  mucous  membrane 
receives  a  diminished  supply  of  blood,  the  nerves  are  less  sensitive 
to  excite  normal  movements.  In  age  the  destruction  of  tissue  takes 
place  without  proportionate  repair  of  tissue,  and  emaciation  is  the 
result:  but  this  emaciation  may  be  so  great  and  the  circulation  so 
enfeebled  that  the  patient  suffers  from  anaesthesia  and  disturbed 
sensation  in  varied  parts.  It  may  be  merely  numbness  in  the  hands 
and  feet,  or  pain,  cramp,  sensation  as  of  "pins  and  needles."  The 
special  senses  may  be  also  disturbed,  and  both  sight  and  hearing 
affected,  or  the  brain  may  be  unable  to  carry  on  its  functions  and 
syncope  and  vertigo  may  follow.  Distressing  symptoms  may  ensue 
upon  the  introduction  of  food  into  the  stomach;  the  food  remains 
undigested,  it  produces  pain  and  a  sense  of  weight,  headache,  flatu- 
lence, and  sometimes  the  symptoms  just  referred  to,  vertigo,  disturbed 
vision,  and  even  syncope.  These  effects  of  indigestion  are  more 
severe  if  associated  with  another  frequent  trouble  of  advanced  life, 
namely,  an  inactive  state  of  the  colon,  for  if  the  transverse  colon  be 
distended  the  gastric  affection  is  rendered  more  severe.  It  is  sur- 
prising how  gradual  is  the  failure  of  power  of  the  stomach :  and  we 
frequently  remark  how  greatly  the  functional  activity  is  reduced 
without  the  loss  of  life.  For  months  life  may  be  sustained  with  only 
a  very  small  supply  of  food,  when  there  are  no  great  demands  upon 
the  strength ;  in  extreme  age,  a  cup  of  milk  or  of  arrowroot  may  be 
almost  the  only  sustaining  food  partaken  of  week  after  week.  In 
the  treatment  of  this  condition  we  must  bear  in  mind  that  we  have 
to  cope  not  so  much  with  actual  disease  as  to  retard  a  degenerative 
process ;  the  diet  should  be  carefully  regulated,  it  should  be  of  a 
nourishing  kind,  and  as  large  meals  cannot  be  taken,  a  shorter  inter- 
val between  them  should  be  allowed  than  in  ordinary  health ;  and 
if  there  be  wakefulness  at  night  or  restlessness,  some  fluid  nourish- 
ment should  be  taken,  especially  between  two  and  four  in  the  morning. 

Alcoholic  stimulants  are  often  taken  at  this  age  with  advantage, 
and  other  stimulants  as  ammonia  combined  with  vegetable  bitters  ; 
stimulating  condiments  may  be  useful,  as  mustard  and  the  various 
peppers,  &c.  As  to  other  tonics,  nux  vomica  or  its  alkaloid  strych- 
nia, nitro-hydrochloric  acid,  and  the  milder  preparations  of  steel, 
may  be  given.  If  the  bowels  are  inactive,  an  aloetic  dinner  pill 
with  nux  vomica  and  soap,  or  with  guaiacum  is  often  very  useful. 
Large-meals  should  be  avoided,  so  also  the  immoderate  use  of  tobacco 
and  of  tea. 

Another  form  of  atonic  dyspepsia  is  that  connected  with  exhaustion 
of  the  cerebro-spinal  system  of  nerves  ;  here  also  there  appears  to  be  a 
deficiency  of  gastric  juice,  probably  from  an  anaemic  state  of  the 
mucous  membrane,  and  it  may  be  produced  by  sedentary  occupation, 
want  of  exercise,  mental  distress,  over-excitement,  and  anxiety. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  213 

The  nervous  energy  of,  and  the  vascular  supply  to  the  digestive 
organs,  appear  to  be  inadequate  to  their  requirements,  and  digestion 
becomes  oftentimes  a  painful  process,  from  which  the  patient  shrinks. 
This  state  is  marked  by  pallor,  and  by  an  anxious  expression  of  the 
countenance ;  the  appetite  is  lost,  or  it  is  a  fastidious  one  ;  the  pulse 
is  sharp,  irritable,  but  compressible ;  palpitation  of  the  heart,  throb- 
bing sensations,  and  often  pain  in  the  head,  are  produced  ;  the  tongue 
is  slightly  injected  in  its  papillae,  and  has  a  whitish  fur  upon  it, 
though  in  many  cases  the  tongue  is  clean,  large,  and  indented;  there 
is  sometimes  nausea,  or  actual  vomiting ;  the  bowels  are  constipated 
or  irregular ;  a  sense  of  oppression  or  weight  comes  on  after  eating, 
sometimes  followed  by  a  throbbing  sensation  in  the  abdomen,  and 
almost  over  the  whole  body,  with  languor  or  drowsiness ;  at  other 
times  there  is  faintness ;  and  when  undigested  food  passes  into  the 
pylorus  and  duodenum,  violent  cramp  or  spasmodic  pain  is  produced. 

The  ingesta  may  be  retained  in  the  stomach  for  many  hours,  and 
in  some  cases  even  days  in  a  crude  state ;  the  secretion  is  not  suffi- 
cient to  dissolve  what  is  placed  in  the  viscus ;  the  irritation  produced 
by  the  retained  food  aggravates  the  ailment,  and  fermentation  or 
decomposition  is  set  up,  with  flatulence,  pain,  heartburn,  or  severe 
gastralgia.  These  symptoms,  however,  may  arise  from  excess  of 
food  rather  than  from  diminished  solvent  power,  as  we  have  pre- 
viously noticed.  When  the  nervous  power  is  thus  weakened  the 
process  of  digestion  is  sometimes  watched  with  the  most  scrutinizing 
care  ;  one  kind  of  food  after  another  is  said  to  produce  pain  and  is 
left  off;  digestion  is  said  to  be  so  slow  that  a  long  interval  must 
elapse  before  further  supplies  are  taken,  life  is  rendered  miserable, 
and  the  patient  complains  of  inability  to  attend  to  ordinary  duties ; 
some  of  these  instances  of  indigestion  from  exhaustion  pass  into  the 
condition  of  great  nervous  irritability,  marked  by  severe  neuralgic 
pain,  or  by  great  irritability  of  the  stomach. 

Eecovery  takes  place,  but  it  is  often  greatly  protracted.  In  the 
treatment  it  is  unwise  to  underrate  the  sufferings  and  distress  of  the 
patient.  Stimulants  afford  relief,  but  must  be  used  with  great  cau- 
tion, otherwise  they  will  be  taken  at  irregular  times  without  corre- 
sponding nourishment;  the  mucous  membrane  of  the  stomach  will 
then  become  irritated  and  congested,  subacute  gastritis  and  all  the 
symptoms  of  congestive  dyspepsia  will  be  produced,  and  the  second 
disease  will  be  tenfold  worse  than  the  first,  for  a  craving  for  alcoholic 
stimulants  may  be  induced.  Patients  should  be  encouraged  to  take 
suitable  nourishment,  to  masticate  it  properly,  and  exercise  in  the 
open  air  should,  if  possible,  be  taken  daily.  Constipation  should  be 
relieved  by  aloes  and  myrrh,  or  by  colocynth  and  henbane,  with  or 
without  extract  of  nux  vomica ;  a  dose  of  blue  pill  or  of  oxide  of 
mercury  is  sometimes  of  advantage ;  and  to  rectify  the  condition  of 
the  stomach,  capsicum  with  small  quantities  of  ipecacuanha  may  be 
given  to  increase  the  secretion ;  dilute  hydrochloric  acid  to  add  to 
its  solvent  power,  or  carbonate  of  ammonia  with  bitter  infusions  to 
stimulate  the  vascular  and  nervous  systems  of  the  abdominal  organs. 


214  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

Or  the  dilute  phosphoric  acid  with  tincture  of  nux  vomica,  or  with 
three  to  five  minims  of  the  solution  of  strychnia,  may  be  given. 

Some  years  ago  Dr.  Ballard1  introduced  into  English  practice,  ac- 
cording to  the  suggestion  of  M.  Corvisart,  an  artificial  digestive 
compound,  in  the  form  of  pepsin,  prepared  from  the  stomach  of  rumi- 
nants. This  constitutes  the  basis  of  the  various  kinds  of  "Poudre 
Nutrimentive"  (Boudault).  I  have  not  met  with  the  success  ex- 
pected from  this  remedy ;  but  when  properly  prepared  as  by  Mr. 
Squire,  and  given  in  doses  of  two  to  five  grains  combined  with  dilute 
hydrochloric  acid,  pepsin  promotes  digestion,  and  has  in  some  cases 
proved  of  great  service.  In  all  cases,  however,  it  is  desirable  to 
remove  the  causes  of  the  imperfect  secretion,  if  possible,  rather  than 
to  supply  a  very  imperfect  artificial  substitute. 

The  stimulant  effects  of  coffee,  ammonia,  &c.,  are  not  so  effective 
as  those  of  alcohol  in  these  cases,  and  brandy  or  wine  is  often  better 
than  malt  liquor.  In  saying  this  we  are  very  far  from  recommend- 
ing the  habitual  use  of  such  stimulants. 

The  habit  of  smoking,  or  snuff-taking,  produces  a  relaxed  and 
enfeebled  condition  of  the  mucous  membrane,  the  secretions  of  which 
become  insufficient  to  insure  solution  of  the  food;  stimulants  are 
often  resorted  to,  to  counteract  this  effect,  and  many  suffer  severe 
dyspepsia  from  this  cause. 

In  a  third  form  of  atonic  dyspepsia  the  defective  condition  of  the 
gastric  secretion  and  of  the  power  of  digestion  is  connected  with  the 
state  of  the  nerve  of  nutrition,  as  it  has  bee"n  termed,  the  vaso-motor 
or  sympathetic  nerve. 

During  chronic  disease,  as  phthisis,  the  power  to  digest  food  seerns 
to  fail  entirely  in  some  cases ;  the  symptoms  of  chest  disease  may  be 
relieved,  but  the  patient  cannot  take  food,  and  if  constrained  to 
swallow  it,  it  does  not  digest ;  this  may  be  quite  independent  of  the 
state  so  often  found  at  the  close  of  chronic  disease  in  which  the 
mouth  becomes  aphthous,  the  tongue  red  and  clean,  almost  like  raw 
meat,  the  gums  spongy,  the  throat  sensitive,  and  the  gullet  irritable. 

In  extreme  poverty  and  want — in  starvation — we  do  not  find  the 
craving  for  food  that  some  would  imagine,  but  the  appetite  may  be 
almost  destroyed  from  exhaustion.  There  is  sallowness  of  counte- 
nance, the  eye  is  sunken,  the  tongue  clean  or  irregularly  furred, 
injected  at  the  tip  and  edges,  there  is  irritable  cough,  the  pulse  is 
irritable  but  compressible,  there  is  pain  at  the  scrobiculus  cordis,  the 
stomach  is  very  sensitive  and  the  bowels  easily  disturbed.  It  would 
be  very  unwise  to  place  food  of  a  kind  difficult  of  digestion  in  a 
stomach  so  enfeebled ;  the  gentlest  measures  must  be  used ;  stimu- 
lants cautiously  used,  and  by  degrees,  more  sustaining  nourishment 
allowed. 

Another  cause  of  this  nervous  exhaustion  is  that  observed  in 
young  persons  during  rapid  growth,  and  during  climacteric  changes, 
as  at  the  commencement  of  menstruation  ;  there  is  gradually  increas- 
ing weakness  and  loss  of  strength,  the  countenance  becoming  pale, 

1  Ballard,  'On  Artificial  Digestion.' 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  '215 

the  lips  blanched,  there  is  inactivity  of  both  mind  and  body,  and 
frequently  severe  headache,  sometimes  intense  in  character,  on  one 
temple,  or  in  one  eye,  or  it  may  be  at  the  vertex ;  the  pupils  are 
dilated,  the  tongue  pale,  the  bowels  generally  confined,  the  pulse 
compressible,  the  blood  is  generally  deficient  in  red  corpuscles,  and 
in  young  women  this  state  passes  into  what  is  designated  chlorosis ; 
the  menstruation  becomes  scanty  or  it  ceases  altogether,  there  is 
venous  murmur  in  the  neck,  systolic  bruit  over  the  aortic  valves, 
the  nervous  system  is  disturbed,  and  pain  is  easily  induced ;  it  is 
generally  complained  of  in  the  left  side  below  the  left  breast,  in  a 
small  circumscribed  space.  In  this  state  of  general  weakness  diges- 
tion is  impaired,  and  it  is  on  this  account  especially  that  we  refet  to 
the  state  at  all ;  the  appetite  is  perverted  or  lost,  patients  will  take 
scarcely  any  food  of  a  nourishing  kind,  a  little  tea  and  bread,  or 
sweets,  and  the  like.  Sometimes  the  stomach  is  irritable,  and  there 
is  pain  at  the  scrobiculus  cordis,  food  is  rejected  at  once,  and  although 
scarcely  anything  is  retained  there  may  be  a  plumpness  of  the  sys- 
tem, which  shows  that  some  portion  of  nourishment  is  absorbed. 
The  vomiting  appears  to  take  place  as  soon  as  the  food  reaches  the 
stomach;  it  has  been  well  designated  "hysterical  stomach"  and 
"  regurgitative  disease  of  the  stomach."  Sometimes,  however,  the 
emaciation  is  extreme.  So,  again,  when  there  is  complete  anorexia, 
and  determination  not  to  take  food,  the  wasting  necessarily  becomes 
very  great.  Intense  neuralgic  pain  is  another  of  the  indications  of 
exhausted  nervous  power.  This  form  of  indigestion  may  be  greatly 
relieved  by  the  judicious  use  of  chalybeate  medicines,  and  it  is  well 
to  begin  with  the  milder  preparations,  as  the  ammonio-citrate  of 
iron,  which  may  be  conveniently  given  in  an  effervescent  form ;  the 
bowels  should  be  relieved  by  aloetic  aperients,  but  it  is  most  import- 
ant to  insist  on  a  nourishing  diet,  as  milk,  cocoa,  meat,  vegetables ; 
and  malt  liquors,  as  good  draught  stout,  are  of  great  service.  If 
the  imperfect  nutrition  goes  on  there  is  fear  of  tubercular  formation 
and  its  attendant  subsequent  changes. 

Another  condition  of  indigestion  is  that  associated  with  the  ex- 
haustion consequent  upon  child-bearing^  over-lactation,  repeated  hemor- 
rhages, &c.,  the  face  becomes  sallow,  blanched,  the  forehead  often 
irregularly  bronzed,  there  is  headache,  neuralgia,  pain  at  the  top  of 
the  head,  ringing  noise  in  the  ears,  the  eyes  are  intolerant  of  light, 
the  pulse  is  compressible,  the  mind  often  becomes  disturbed,  delusions 
may  distress  the  patient,  and  the  appetite  is  gone.  The  stomach  in 
this  state  often  becomes  irritable,  and  there  is  a  sensation  of  emptiness 
or  faintness.  This  condition  is  one  requiring  careful  treatment,  for 
stimulants  are  'of  great  value,  but  require  extreme  care,  for  the  relief 
afforded  prompts  to  the  continuance  of  the  remedy  when  the  disease 
has  passed  away.  In  these  patients  the  heart  becomes  feeble,  there 
is  faintness,  and  strong  stimulants  are  at  once  resorted  to  to  relieve 
the  distress. 

Carbonate  of  ammonia,  with  aromatics  and  bitter  infusions,  may 
be  used,  and  steel  at  first  in  small  doses  and  in  the  milder  prepara- 


216  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

tions;  afterwards  mineral  acids,  as  previously  mentioned,  and  qui- 
nine, strychnia,  &c.,  should  be  given. 

In  very  stout  persons,  or  in  those  in  whom  the  appetite  has  pre- 
viously been  pampered,  we  find  feebleness  of  digestion,  with  a  sense 
of  weight  or  exhaustion;  spasmodic  pain  also,  and  irregular  action 
of  the  heart  are  easily  induced.  These  symptoms  arise  in  part  from 
the  feeble  condition  of  the  heart  and  circulation,  and  are  increased  by 
an  inactive  state  of  the  liver.  The  appetite  is  often  small  in  stout 
persons ;  and  the  hydrocarbons  are  stored  up,  instead  of  being  re- 
moved in  the  ordinary  changes  of  respiration ;  but  the  mischief  is 
still  further  increased  when  the  heart  is  irregular  from  an  excess  of 
fat  about  it,  or  when  the  feeble  circulation  of  the  brain  manifests 
itself  in  vertigo  and  disordered  sensations.  Much  relief  is  afforded 
by  occasional  alteratives,  by  aloes,  rhubarb,  and  taraxacum,  or  by 
nitro-hydrochloric  acid  with  bitter  infusions ;  stimulants  should  be 
avoided  if  possible,  and  out-door  exercise  gradually  increased. 

Dyspepsia  is  also  occasioned  by  an  excessive  secretion  of  gastric 
juice.,  which  is  apparently,  in  some  cases,  poured  out  in  unusual 
quantity  from  a  slight  stimulant.  A  burning  sensation  at  the  stomach 
two  or  three  hours  after  a  meal,  heartburn,  pain  in  the  back,  are  the 
usual  symptoms  of  this  state.  It  may  be  associated  with  hepatic  or 
with  cerebral  disease,  and  it  is  then  best  combated  by  remedial 
agents  calculated  to  relieve  the  exciting  cause  of  the  disease;  imper- 
fect secondary  assimilation,  such  as  exists  in  gout  and  in  rheumatism, 
produces  symptoms  similar  to  those  just  mentioned,  and  they  are 
probably  due  to  a  changed  character  of  the  secretion  rather  than  to 
mere  excess. 

In  the  treatment  of  this  form  of  dyspepsia  the  diet  should  not 
contain  an  excess  of  nitrogenous  substances;  and  food  should  be 
slowly  and  thoroughly  masticated;  it  is  also  important  not  to  limit 
the  patient  to  fluid  forms  of  food  which  are  rapidly  absorbed,  and 
often  leave  an  undigested  sedimentary  deposit ;  the  evil  of  this  form 
of  dietary  we  have  often  seen  in  chronic  disease,  in  which  dyspepsia 
has  apparently  been  produced,  or,  at  least,  aggravated  by  this  cause. 
Stimulants  are  better  avoided,  or  they  should  be  taken  in  great 
moderation  ;  whilst  ardent  spirits,  and  the  stronger  wines  are  better 
abstained  from  altogether,  for  a  temporary  relief  does  not  compensate 
for  the  injury  they  perpetuate.  Exercise,  and  the  maintenance  of 
good  action  from  the  skin  are  very  important,  especially  when  this 
gastric  disturbance  is  combined  with  hepatic  derangement. 

As  to  other  remedies,  the  carbonate  or  caustic  alkalies  with  bitter 
infusions  often  afford  almost  immediate  relief;  but  they  do  not 
remove  the  cause  of  the  malady,  and  are  ineffective  unless  the  diet 
b3  regulated,  and  right  exercise  maintained.  Creasote  or  carbolic 
acid,  combined  with  sedatives  and  aperients,  greatly  mitigate  the 
distressing  symptoms;  and  in  all  these  cases  it  is  well  carefully  to 
watch  that  the  bowels  are  not  confined,  and  that  the  liver  performs 
its  functions.  It  is  not  necessary,  however,  to  resort  continually  to 
blue  pill  or  calomel  to  rectify  any  deviation  from  healthy  action  in 
the  hepatic  secretion. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  217 

Dyspepsia  from  an  irregular  secretion  of  the  gastric  juice  is  closely 
allied  to  the  state  just  described.  Such  irregularity  Dr.  Budd  has 
mentioned  as  one  cause  of  the  varied  degrees  of  gastric  solution 
observed  after  death,  where  other  conditions  have  previously  been 
the  same.  He  states,  very  truly,  that  whilst  in  health  the  stimulus 
of  food  leads  to  the  effusion  of  gastric  juice,  in  disease  it  may  be 
poured  out  without  this  stimulus.  In  organic  cerebral  disease,  and 
also  in  gastric  disease  connected  with  disturbance  of  the  nervous 
system  of  a  functional  kind,  a  perverted  and  craving  appetite,  and 
desire  for  food  at  unusual  periods,  may  be  due  to  this  irregular 
secretion  ;  and,  it  is  not  uncommon  to  find  those  who  suffer  at  irregu- 
lar periods  from  burning  pain  at  the  stomach,  which  is  at  once  re- 
lieved by  partaking  of  a  mouthful  of  biscuit  or  dry  bread.  When 
the  complaint  arises  from  gastric  causes,  the  directions  we  have 
briefly  given  for  the  relief  of  the  excessive  secretion  of  gastric  juice, 
may  be  found  of  service ;  but  where  it  arises  from  the  former, 
namely,  from  cerebral  disease,  other  symptoms  will  be  generally 
present,  such  as  pain  in  the  head,  a  slow  and  laboring  pulse,  .dis- 
turbed special  or  general  sensibility.  In  this  case,  a  spare  and 
unstimulating  diet  is  called  for;  the  free  action  of  the  bowels  is 
desirable  and  the  avoidance  of  all  causes  of  mental  excitement  is 
most  important.  Too  frequently  in  children  a  ravenous  appetite  is 
found  to  be  the  precursor  of  organic  disease  of  the  brain ;  and  in 
mania  the  sufferer  is  oftentimes  prompted  to  swallow  the  most  extra- 
ordinary substances,  as  large  quantities  of  gravel,  possibly  from  a 
sense  of  gastric  distress,  and  of  unsatisfied  morbid  appetite. 

Dyspepsia  produced  by  morbid  changes  in  the  gastric  secretion 
leads  us  to  other  symptoms  of  disease ;  and  the  first  that  we  have 
to  notice  is  Pyrosis  or  water-brash.  This  is  a  symptom  of  frequent 
occurrence,  and  it  receives  its  appellation  from  the  fact  of  its  con- 
sisting in  the  rejection  of  a  thin  watery  mucus.  Haifa  pint  of  thin 
watery  fluid,  sometimes  resembling  the  white  of  an  egg,  is  occasion- 
ally vomited  or  regurgitated  at  once ;  it«is  generally  neutral  in  its 
chemical  reaction,  and  often  tasteless,  but  sometimes  it  is  found  to 
be  slightly  alkaline,  and  the  patient  complains  of  its  saltness.  The 
period  at  which  the  discharge  of  fluid  takes  place  varies  both  as  to 
the  hour  of  the  day,  and  the  frequency  of  the  occurrence  of  the 
attack.  The  vomiting,  however,  generally  occurs  when  the  stomach 
is  empty;  and  it  is  accompanied  with  a  sense  of  contraction  and  of 
pain  at  the  epigastric  region  and  at  the  spine ;  with  some  patients 
the  attack  comes  on  in  the  forenoon,  with  others  during  the  night, 
as  at  one  or  two  in  the  morning,  that  is  to  say,  several  hours  after 
retiring  to  rest.  As  to  the  other  symptoms,  the  tongue  may  be  clean, 
the  pulse  normal ;  the  patient  tolerably  nourished,  or  anaemic  and 
enfeebled ;  headache  is  often  present,  and  in  some  instances  the  water- 
brash  alternates  with  more  severe  gastralgia,  and  often  with  mental 
languor  and  depression. 

It  is  the  opinion  of  Dr.  Handfield  Jones1  that  pyrosis  is  a  chronic 

1  Handfield  Jones,  'On  the  Mucous  Membrane  of  the  Stomach.' 


218  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

catarrh  of  the  mucous  membrane  of  the  stomach,  similar  to  blenor- 
rhcea  from  the  bronchi ;  there  is  much  to  warrant  this  supposition. 
Dr.  Chambers,1  however,  favors  the  idea  that  the  oesophagus  is  the 
source  of  the  discharge,  and  it  may  be  that  pancreatic  secretion  is 
regurgitated  into  the  stomach  and  then  rejected.  The  disease  comes 
on  after  the  continued  use  of  oatmeal,  and  hence  it  is  more  common 
in  the  north  ;  it  may  follow  symptoms  of  chronic  gastritis ;  and  it  is 
produced  by  great  anxiety  of  mind,  by  exhaustive  disease,  by  over- 
fatigue,  or  by  an  overworked  frame  ;  it  also  occurs  during  pregnancy, 
and  it  is  met  with  amongst  the  symptoms  of  commencing  cancerous 
disease  of  the  stomach.  With  such  causes,  it  is  not  surprising  that 
numerous  instances  of  this  disease  are  found  among  the  out-patients 
of  dispensaries  and  large  hospitals. 

The  remedies  which  relieve  pyrosis  are  astringents  and  tonics,  as 
the  sulphate  of  iron  with  the  extract  of  logwood  ;  quinine  with  aloes 
and  myrrh ;  nitrate  of  bismuth  alone  or  with  conium  and  nux 
vomica ;  an  alterative  of  blue  pill,  with  rhubarb,  is  sometimes 
beneficial.  Solution  of  potash,  with  hydrocyanic  acid  or  with  hen- 
bane and  bitter  infusion,  is  of  great  service  when  there  is  much  pain. 
Other  astringents  may  be  advantageously  employed  with  sedatives, 
anodynes,  and  tonics,  as  the  compound  Kino  powder,  catechu  with 
morphia  or  opium,  oxide  of  silver,  sulphate  of  copper,  strychnia,  or 
the  infusion,  tincture  or  extract  of  nux  vomica. 

A  form  of  pyrosis  is  found  to  arise  in  connection  with  colloid 
cancer,  watery  fluid  being  regurgitated  into  the  mouth ;  and  it  is 
important  to  bear  this  fact  in  mind  in  the  diagnosis  of  colloid  disease  ; 
and  in  ordinary  pyrosis  the  symptoms  are  sometimes  so  severe  and 
persistent  as  to  cause  hesitancy  in  our  prognosis,  and  to  suggest  the 
presence  of  carcinomatous  disease. 

Beside  the  abnormal  conditions  of  the  gastric  juice  already  men- 
tioned, there  are  two  others  which  must  be  considered,  namely,  the 
dyspepsia  occurring  in  what  has  been  termed  the  lithic  acid  diathesis, 
and  the  dyspepsia  found  in  albuminuria.  The  former  is  especially 
observed  in  those  who  are  the  subjects  of  rheumatism  and  of  gout, 
and  the  following  symptoms  mark  its  presence: — A  fastidious  appe- 
tite, heartburn,  flushes  of  heat,  pain  at  the  scrobiculus  cordis  and  in 
the  left  hypochondriac  region,  a  constipated  or  irregular  condition  of 
the  bowels,  a  furred  tongue,  pain  in  the  head,  mental  depression  or 
unusual  excitement,  and  sometimes  severe  vomiting  and  intense  pain 
at  the  stomach. 

The  disease  appears  to  be  produced  by  imperfect  secondary  assimi- 
lation, as  explained  by  Dr.  Prout.  The  functions  of  other  viscera 
are  disordered,  particularly  of  the  liver  and  kidneys;  the  motions 
become  pale,  the  urine  high-colored,  and  it  deposits  lithates,  or  it 
contains  an  excess  of  uric  acid.  The  heart  and  sympathetic  nerve 
are  affected ;  there  is  often  irregularity  of  the  pulse,  and  there  may 
also  be  vertigo  or  transient  anaesthesia.  The  blood  contains  lithic 
acid,  as  shown  by  Dr.  Garrod,  or  other  elements  from  the  decompo- 

1  Chambers,  '  On  Digestion.' 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  219 

sition  of  tissue ;  and  in  this  state  the  gastric  juice  has  an  abnormal 
character;  it  becomes  preternaturally  acid  from  lactic  or  hydro- 
chloric acids,  or  is  excessive  in  quantity,  and  may  be  otherwise 
changed. 

This  form  of  d}^spepsia  is  easily  produced  when  hereditary  ten- 
dency exists ;  but,  even  where  this  is  not  the  case,  it  may  arise  from 
over-stimulating  diet,  from  excess,  and  from  other  irregularities. 

In  few  dyspeptic  conditions  is  the  regulation  of  the  diet  more  im- 
portant, both  as  to  its  quality  and  its  quantity  ;  and  it  should  consist 
of  well-cooked,  plain,  animal  food,  with  vegetables,  the  latter  being 
in  excess.  Stimulants  should  be  avoided,  or  the  lighter  wines  taken ; 
for  although  the  immediate  distress  is  relieved  by  ardent  spirits,  the 
disease  is  subsequently  aggravated. 

As  to  medical  treatment,  the  first  object  is  to  mitigate  present  dis- 
tress and  pain ;  if  the  suffering  be  severe,  chloric  ether,  chlorodyne, 
opium,  or  morphia  may  be  resorted  to  ;  the  salts  of  potash,  soda,  and 
magnesia  afford  relief  to  the  heartburn  and  distress,  and  may  be 
combined  with  carminative  or  antispasmodic  remedies.  Charcoal  will 
often  relieve  the  flatulent  distension,  and  may  be  taken  in  the  form 
of  capsules,  or  merely  mixed  with  some  fluid,  as  milk  or  gruel.  It 
is,  however,  most  desirable  to  remove,  if  possible,  the  cause  of  the 
disease,  namely,  the  secondary  mal-assimilation  ;  and  to  correct  an 
inactive  condition  of  the  liver,  if  such  a  state  exists,  small  doses  of 
blue  pill  may  be  combined  with  colchicum,  rhubarb,  aloes,  and  some- 
times also,  with  quinine.  Taraxacum  with  bitter  infusions,  and  with 
the  alkaline  bicarbonates,  acts  sometimes  as  a  useful  laxative.  If, 
however,  there  be  exhaustion  and  general  feebleness  of  power, 
ammoniacal  stimulants  must  be  given  in  combination,  and  wine 
allowed.  The  saline  mineral  waters  are  in  some  of  these  instances 
justly  recommended  ;  those  of  Bath,  Bristol,  Buxton,  and  of  Chelten- 
ham are  most  likely  to  be  of  service  amongst  British  springs ;  and 
on  the  Continent,  the  springs  at  Homburg,  Wiesbaden,  Ems,  Karls- 
bad, and  Vichy  may  be  resorted  to.  Kissingen  also  and  many  other 
places. 

Nothing  will  avail  effectually,  however,  unless  strict  dietetic  rules 
be  observed,  accompanied  by  exercise  in  the  open  air.  If  the  meals 
be  daily  hurried,  the  mind  constantly  on  the  stretch  from  business 
occupations,  the  hours  of  rest  shortened,  and  the  consequent  ex- 
haustion removed  by  stimulating  potions,  the  physician  has  no 
chance  of  affording  relief. 

In  albuminuria,  the  vomiting  and  nausea,  which  are  amongst  its 
most  common  symptoms,  are  generally  considered  as  sympathetic ; 
and  the  renal  plexus  of  nerves,  in  its  connection  with  the  semilunar 
ganglion,  with  the  pneumogastric  nerves,  and  with  the  gastric  plexus, 
is  regarded  as  the  exciting  cause  of  the  vomiting  and  nausea.  This 
is  probably  in  great  measure  the  case;  but  another  cause  exists, 
namely,  the  altered  condition  of  the  blood,  and  the  excess  of  urea 
which  it  contains ;  the  urea  is  poured  out  with  the  normal  gastric 
juice,  and  acts  as  an  irritant  to  the  stomach,  and  tends  to  neutralize 
the  gastric  juice.  Urea  has  been  demonstrated  in  the  secretion  from 


220  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

the  bronchi,  and  it  is  probable  that,  in  these  cases,  it  exists  in  all  the 
secretions ;  but  perhaps,  in  none,  to  a  greater  degree  than  in  that 
from  the  stomach.1  It  is  in  vain  to  expect  much  relief  from  reme- 
dies directly  applied  to  the  stomach ;  attention  must  rather  be  given 
to  the  disease  of  the  kidney,  and  means  employed  calculated  to 
restore  the  blood  to  its  normal  state,  or  to  free  it  from  poisonous 
excreta. 

Diaphoretics,  as  antimony  with  acetate  of  ammonia,  and  salines ; 
purgatives,  as  jalap  or  elateriurn ;  warm  baths  or  vapor  baths  will 
afford  more  relief  than  hydrocyanic  acid  or  creasote  ;  and  cupping 
from  the  loins  will  sometimes  remove,  or,  at  least,  greatly  mitigate 
the  nausea  and  vomiting;  counter-irritation  may  be  applied  to  the 
loins  or  to  the  scrobiculus  cordis;  and  in  some  instances  of  extreme 
general  anasarca,  the  gastric  symptoms  and  the  distress  of  the  patient 
are  greatly  diminished  by  puncturing  the  thighs  and  thus  allowing 
the  serum  gradually  to  exude. 

There  are  other  forms  of  mal  assimilation  which  occasion  dys- 
pepsia, and  we  find  indications  of  this  in  some  of  the  varieties  of 
cutaneous  disease.  No  organ  sympathizes  more  closely  with  the 
stomach  than  the  skin  ;  in  every  period  of  life  this  fact  is  noticed ; 
in  infants  we  have  strophulus,  and  eczema  from  gastric  irritation ; 
in  adults  some  of  the  forms  of  urticaria  and  roseola,  eczema,  and 
lepra ;  in  advanced  life  eczema  and  prurigo,  &c. 

It  not  unfrequently  happens  that  flatulence  is  produced  by  the 
formation  of  gas  in  the  stomach,  irrespective  of  the  decomposition 
of  food,  to  which  reference  will  subsequently  be  made ;  and  in  cases 
of  hysteria,  or  in  prolonged  abstinence  from  food,  &c.,  the  stomach 
sometimes  becomes  painful ty  distended,  eructations  take  place,  and 
the  power  of  digestion  is  diminished.  It  has  been  supposed  that  gas 
is  effused  from  the  capillaries,  but  of  this  we  have  no  proof;  and 
equally  hypothetical  is  the  opinion  that  it  arises  from  mucus  becom- 
ing decomposed  by  gastric  juice,  and  thus  evolving  gaseous  products; 
the  flatulence  is  generally  preceded  by  slight  pain,  or  by  a  gnawing 
sensation  at  the  scrobiculus  cordis ;  a  full  meal  in  this  condition  will 
probably  not  be  digested,  but  the  flatulence  will  be  prolonged,  and 
colic  be  produced.  The  better  method  is  to  take  a  small  quantity  of 
nourishment,  with  some  stimulant — a  cup  of  coffee,  or  a  glass  of 
wine — and  afterwards  a  more  substantial  repast,  giving  time  for 
thorough  mastication.  Charcoal  may  in  some  cases  speedily  relieve 
this  symptom,  but  it  is  more  advisable  to  try  and  remove  the  cause. 

We  have  next  to  consider  those  conditions  of  functional  disease  of 
the  stomach  in  which  the  vascular  supply  is  disturbed,  whether  in 
acute  or  chronic  congestion. 

The  experiments  and  observations  of  Dr.  Beaumont  on  Alexis  St. 
Martin  have  pointed  out  the  state  of  the  mucous  membrane  which 
sometimes  exists  after  improper  food  or  stimulants  have  been  taken  ; 
the  surface  of  the  stomach  was  found  in  such  cases  much  injected,  or 
erythematous.  The  secretion  was  diminished,  and  during  this  period 

1  Bernard,  also  Goodfellow,  'On  Diseases  of  the  Kidney.' 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  221 

more  or  less  discomfort  was  generally  produced;  this  condition 
entirely  ceased  in  a  short  time,  and  the  surface  presented  its  usual 
appearance ;  but  if  death  had  taken  place  from  some  other  cause 
during  that  condition  of  dyspepsia,  the  abnormal  state  would  also 
have  disappeared,  and  no  structural  lesion  would  have  been  dis- 
covered on  careful  or  even  microscopical  inspection.  This  form  of 
dyspepsia  is  perhaps  one  of  the  simplest  degrees  of  acute  catarrh  or 
erythema,  of  which  mention  has  been  made  in  the  last  chapter. 

After  intemperance,  either  in  eating  or  drinking,  the  gastric 
mucous  membrane  becomes  over-stimulated,  the  portal  system  is  at 
the  same  time  engorged,  and  the  liver  is  congested  and  disordered ; 
in  this  state  natural  secretion  does  not  take  place  in  the  stomach, 
and  dyspepsia  is  produced. 

In  this  hyperaemia  or  erythema  of  the  gastric  mucous  membrane 
the  complexion  becomes  slightly  sallow,  and  the  patient  complains 
of  mental  depression,  lassitude,  or  headache ;  the  tongue  is  furred, 
the  appetite  is  impaired,  and  the  condition  of  the  bowels  is  dis- 
ordered, as  shown  by  a  confined  state,  or  by  irregular  action,  with 
more  or  less  pain.  In  some  cases  pain  comes  on  at  the  scrobiculus 
cordis  and  between  the  shoulders,  with  thirst,  nausea,  and  vomiting, 
and  often  with  the  rejection  of  green  bilious  fluid. 

When  excess  is  habitual  the  same  symptoms  are  produced  in  a 
modified  degree ;  the  patient  is  hypochondriacal ;  he  often  believes 
himself  to  be  the  subject  of  serious  disease  of  the  liver ;  the  bowels  are 
constipated  or  irregular ;  flatulence,  spasmodic  pain  or  cramp  in  the 
abdomen,  pain  across  the  chest,  tenderness  at  the  scrobiculus  cordis 
are  produced ;  the  .tongue  is  furred,  or  its  papillae  are  distinct  and 
injected,  the  appetite  is  lost,  especially  in  the  morning,  stimulants 
are  longed  for,  and  at  the  same  time  a  bitter  or  nauseous  taste  in 
the  mouth  distresses  the  patient ;  the  pulse  is  compressible,  and  a 
sense  of  exhaustion  and  of  physical  fatigue  are  attributed  to  actual 
loss  of  power.  Sometimes  also  there  are  severe  headaches,  vomit- 
ing, disturbed  special  sensibility,  as  indicated  by  double  vision, 
muscse  volitantes,  noises  in  the  ears,  disturbed  general  sensibility, 
as  manifested  by  numbness,  formication,  loss  of  sleep,  or  sleep  dis- 
quieted by  frightful  dreams.  In  this  condition,  food  taken  into  the 
stomach  remains  undigested,  and  there  is  a  sense  of  weight  or  "  load 
at  the  chest ;"  the  thick  mucus  covering  the  congested  membrane 
prevents  the  action  of  the  gastric  juice  on  the  alimentary  mass,  as 
in  the  instances  of  chronic  catarrh  previously  described. 

In  the  treatment  of  dyspepsia  following  excess  an  emetic  may  be 
advisable,  but  not  unfrequently  this  natural  mode  of  relief  takes 
place  spontaneously,  and  the  vomiting  is  preceded  by  pallor  and 
faintness.  If  the  irritability  of  the  stomach  continue,  soda  water  or 
effervescent  salines,  as  the  carbonate  of  potash,  soda,  or  magnesia 
with  citric  acid,  may  be  administered  with  or  without  the  addition 
of  hydrocyanic  acid.  The  carbonic  acid  acts  as  an  anodyne  and 
sedative  to  the  mucous  membrane,  and  the  sedative  compound  which 
is  produced  relieves  the  portal  congestion.  Bismuth  is  often  of  great 
value,  and  may  be  given  with  carbonate  of  soda  and  chloric  ether 


222  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

with  almond  emulsion,  or  with  water  and  in  effervescence  by  means 
of  citric  acid. 

In  this  condition  of  great  irritability  of  the  stomach,  in  which  the 
nausea  and  vomiting  are  sometimes  excessive,  and  the  disrelish  for 
food  well  marked,  even  the  sight  or  smell  of  it  being  distressing  to 
the  patient,  the  administration  of  alkalies  is  more  beneficial  than 
that  of  mineral  acids ;  the  former  act  as  sedatives,  rendering  the 
abnormal  as  well  a&  scanty  secretion  less  irritating,  and  enable  the 
diseased  membrane  more  quickly  to  recover  itself,  and  to  put  forth 
its  proper  secretion  ;  the  latter  act  as  astringents  and  tonics  to  a  re- 
laxed mucous  membrane.  Cold  drinks  and  ice  are  often  craved  for, 
and  when  given  in  moderation  tend  to  relieve  the  congested  state  of 
the  gastric  membrane. 

If  more  chronic  effects  have  been  produced,  small  doses  of  blue 
pill  with  rhubarb,  and  with  magnesian  purgatives,  may  be  useful ; 
for,  by  these  means  the  portal  system  becomes  freed  from  engorge- 
ment, and  proper  secretion  takes  place  ;  should  a  sense  of  exhaustion 
then  continue,  it  is  well  to  give  hydrochloric  or  nitro-hydrochloric 
acids  with  infusion  of  gentian  or  calumba. 

The  diet  should  be  plain  and  easy  of  digestion,  not  rich  or  highly 
seasoned,  and  without  stimulants,  for  medicines  are  of  no  avail,  if 
stimulants  be  continued ;  three  to  four  hours  should  be  allowed  to 
intervene  between  each  meal.  The  character  of  the  diet,  and  the 
quantity  of  the  food  taken  are  most  important  considerations ;  for 
meals  taken  too  frequently  or  in  excess,  may,  equally  with  the  ad- 
ministration of  improper  and  indigestible  substances,  be  the  cause  of 
the  malady.  Before  the  stomach  can  empty  itself  it  is  often  again 
irritated  by  a  fresh  supply ;  numerous  dishes  may  prompt  to  intem- 
perance, and  excess  is  especially  injurious  when  associated  with  late 
hours  and  deficient  exercise.  The  function  of  the  stomach  is  con- 
nected with  the  solution  and  preparation  for  absorption  of  the  nitro- 
geneous  articles  of  diet,  as  they  are  present  in  our  ordinary  animal 
food  ;  and  in  the  conditions  of  active  congestion  and  great  irritability, 
bland  demulcent  and  starchy  substances,  as  milk,  arrowroot,  &c.,  are 
to  be  preferred. 

Again,  imperfect  mastication  increases  the  difficulty  of  digestion ; 
for  the  secretions  of  the  stomach  are  then  unaided  by  the  division  of 
the  food,  and  the  action  of  the  saliva  in  changing  the  starchy  por- 
tions into  saccharine  matter  is  not  duly  performed.  This  defective 
division  of  food  may  arise  not  only  from  the  hurry  of  business  and 
the  force  of  habit ;  but  also,  because  the  agents  of  mastication  are 
destroyed ;  and  the  dentist,  by  restoring  the  teeth,  may  afford  the 
most  effectual  means  of  removing  this  form  of  dyspepsia. 

The  more  severe  forms  of  subacute  gastritis  produced  by  excess, 
and  the  chronic  congestion  in  the  gastric  catarrh  connected  with  pul- 
monary and  cardiac  diseases,  have  been  already  noticed. 

III.  The  state  of  the  nervous  system  is  an  important  consideration 
in  the  study  of  disease  of  the  stomach,  as  the  diseases  of  other  organs 
lead  to  disturbance  of  this  viscus  by  their  nervous  and  sympathetic 
relations  with  it.  The  stomach  receives  its  nervous  supply  from  the 


FUNCTIONAL    DISEASES    OF    THE    STOMACH. 


Dissection  showing  the  distribution  of  the  pneumogastric  nerve  on  the  anterior  surface  of  the 
stomach,  its  extension  to  the  pancreas  and  pylorus,  and  its  connection  with  the  semilunar  gauglia, 
&c.  (a)  oosophageal  extremity  of  the  stomach  ;  (6)  pylorus  ;  (c  c)  pnenmogastric  nerves  ;  (e  e)  branch 
of  the  pneumogastvic  to  the  pancreas,  connected  also  with  the  sympathetic,  and  then  passing  onwards 
to  the  pylorus  ;  (//)  other  branches  to  the  pylorus  ;  (g  g  g  y)  branches  of  the  pneumogastric  nerve 
distributed  on  the  anterior  surface  of  the  stomach,  presenting  a  peculiar  dichotomous  division,  and 
repeated  union  of  its  branches  ;  (h  h  h  h  h  h)  splanchnic  nerves  ;  (i)  aorta  ;  (j)  diaphragmatic  artery, 
with  a  filament  of  nerve  upon  it ;  (k  k)  coronary  artery  ;  (I)  splenic  artery  ;  (m)  hepatic  artery  turned 
aside  from  its  position  in  front  of  the  aorta,  and  from  its  origin  at  the  cosliacaxis  ;  and  thus  it  appears 
to  be  behind  the  aorta  ;  the  large  branches  of  the  sympathetic  nerve  upon  it  are  continuous  with  the 
portion  of  ganglion  (r*)  close  to  the  coronary  artery;  (n)  vena  portse  ;  (o  o)  supr.a-renal  capsules 
receiving  numerous  nerve  filaments  ;  (rr)  semilunar  ganglia,  and  descending  branches  to  the  mesen- 
teric  artery  and  renal  plexus,  &c.  ;  (s)  mesenteric  artery  drawn  aside. 

In  this  distribution  of  nerves,  the  close  sympathy  of  the  stomach  with  the  parts  supplied  by  the 
semiluuar  ganglion  is  explained;  thus,  it  is  brought  into  connection  with  the  liver  by  its  hepatic 
branches  with  the  pancreas,  with  the  diaphragm  and  phrenic  nerve,  with  the  supra-renal  capsules, 
and  by  its  desceuding  branches  with  other  abdominal  viscera. 


224  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

pneuinogastric  nerve,  as  well  as  from  the  vaso  motor  nerve  of  the 
abdomen.  The  pneumogastric  has  its  origin  in  the  brain,  at  the 
floor  of  the  fourth  ventricle,  and  is  brought  into  intimate  relation 
with  other  nerves  arising  at  the  same  part ;  it  then  passes  to  the 
base  of  the  skull,  and  is  united  with  other  nerves,  with  the  spinal 
accessory,  the  facial  and  the  fifth  in  the  neck  ;  it  is  distributed  to 
the  larynx  and  to  the  oesophagus;  in  the  chest  to  the  lungs  and  to 
the  heart,  and  in  the  abdomen  it  is  brought  into  intimate  rela- 
tionship with  the  nerves  of  the  liver  and  pancreas  and  of  the 
kidney,  and  it  unites  with  the  large  sympathetic  ganglia  at  the 
upper  part  of  the  abdominal  aorta.  Hence  the  intimate  relation 
of  the  parts  supplied  by  this  nerve.  In  structural  diseases  of  the 
stomach  the  nervous  supply  is  concerned  in  many  of  the  symptoms 
produced,  as  the  irritability  and  the  severe  pain,  in  ulceration  of  the 
stomach,  and  in  malignant  disease,  but  it  is  with  functional  diseases 
that  we  have  especially  to  do  in  the  present  chapter.  Pain,  or  gas- 
tralgia,  as  it  has  been  technically  called,  irritability  of  the  stomach 
leading  to  nausea  and  vomiting,  loss  of  appetite  or  anorexia,  and 
perverted  appetite,  are  the  symptoms  that  are  produced  in  these 
affections ;  and  it  is  to  the  pneumogastric  nerve,  in  its  extensive 
connections,  that  these  symptoms  are  due.  The  symptoms  just  re- 
ferred to  may  be  caused  by  irritation,  either  at  the  origin  or  at  the 
peripheral  extremity  of  any  of  the  branches  of  this  important  nerve. 
On  examination  it  is  found  that  the  stomach  'itself  is  not  at  fault, 
but  that  the  source  of  its  disturbance  is  elsewhere.  We  will  take 
these  symptoms  seriatim,  and  first  in  reference  to  pain.  Gastralgia 
is  sometimes  very  intense  ;  although  partly  neuralgic,  it  is  the  nerve 
at  its  origin  and  the  state  of  the  whole  nervous  system  that  are  at 
fault.  The  pain  is  irregular  iu  its  onset;  it  is  not  necessarily  con- 
nected with  food ;  in  fact,  it  is  sometimes  relieved  by  food  ;  there  is 
not  the  same  association  with  vomiting  that  we  find  in  gastric  ulcer; 
the  expressions  of  pain  by  the  patient  are  made  in  the  strongest 
language;  it  is  "an  agony,"  the  pain  is  "intense,"  but  the  other 
conditions  do  not  correspond,  and  it  is  found  that  when  the  attention 
of  the  patient  is  diverted  the  pain  ceases.  This  form  of  disease  is 
observed  where  the  nervous  system  has  been  overwrought,  in 
patients  with  hypochondriasis,  in  young  persons  with  disturbed 
menstruation,  with  leucorrhcea  and  dysmenorrhoea.  The  appetite 
is  impaired,  the  bowels  irregular,  vomiting  is  not  usually  present, 
the  tenderness  at  the  stomach  is  not  such  as  we  find  in  organic  dis- 
ease, neither  do  we  find  that  the  remedies  which  relieve  organic  dis- 
ease are  of  service.  Those  remedies  which  strengthen  the  nervous 
system,  as  fresh  air,  strengthening  diet,  cheerful  occupation,  horse 
exercise,  are  of  value,  although  sometimes  opium,  morphia  or  bella- 
donna are  required  to  quiet  the  pain  and  procure  sleep.  It  is  often 
found  that  this  state  is  associated  with  disturbance  of  the  uterine 
functions ;  and  sometimes  it  suddenly  ceases,  but  gives  place  to  irri- 
tation in  some  other  branches  of  the  pneumogastric  nerve. 

Vomiting  and  irritability  of  the  stomach  are  also  common  symp- 
toms of  disturbance  of  the  nerves  of  the  stomach,  both  of  a  primary 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  225 

and  reflex  character ;  in  disease  of  the  brain  these  are  most  impor- 
tant symptoms;  in  tumors  of  the  brain  the  vomiting  comes  on 
nearly  every  day,  at  irregular  times,  but  with  a  clean  tongue  and 
without  connection  with  food,  so  also  in  tubercular  meningitis  and 
in  hydrocephalus ;  at  the  commencement  of  ingravescent  apoplexy 
we  find  that  vomiting  takes  place,  so  also  after  severe  concussion  of 
the  brain  ;  again,  in  some  cases  of  anaemia  of  the  brain  vomiting  is 
induced.1  In  diseases  of  the  larynx  and  of  the  pharynx  we  find  that 
the  irritation  of  the  peripheral  nerves  in  these  parts*causes  vomiting, 
but  still  more  important  are  those  gastric  symptoms  produced  by 
disturbance  of  the  pulmonary  branches  of  the  pneumogastric  nerve. 
In  early  phthisis  the  irritation  from  tubercular  deposit  at  the  apices 
of  the  lungs  causes  violent  vomiting,  sometimes  so  severe  that  the 
thoracic  mischief  may  be  entirely  overlooked.  Another  circum- 
stance often  observed  in  connection  with  these  forms  of  reflex  irri- 
tation is,  that  when  the  thoracic  disease  has  advanced  or  has  be- 
come suddenly  increased  by  the  onset  of  acute  inflammation,  then 
the  gastric  symptoms  cease.  In  cardiac  disease  and  pericardia!  effu- 
sion we  also  find  that  the  stomach  becomes  sympathetically  irritated. 
The  sympathy  of  the  stomach  with  disturbance  of  the  abdominal 
viscera  is  still  more  manifest;  we  find  vomiting  a  very  common 
symptom  of  pregnancy  and  of  ovarian  disease ;  the  vomiting  may 
be  especially  marked  at  the  earlier  period  of  pregnancy ;  but  in 
other  cases  it  continues  throughout  the  whole  course;  so  also  in 
ovarian  disease,  the  irritability  of  the  stomach  is  often  so  decided 
that  the  fear  is  entertained  of  organic  disease  of  the  stomach,  when 
the  sudden  enlargement  of  the  ovary  by  the  distension  of  an  ovarian 
cyst  takes  place,  and  all  the  gastric  symptoms  cease.  During  the 
passage  of  gall-stone  vomiting  is  an  almost  constant  symptom,  as 
well  as  in  diseases  of  the  liver;  it  is  seen  in  renal  calculus,  as  well 
as  in  many  forms  of  renal  disease ;  in  intestinal  obstruction,  in  dis- 
ease of  the  supra-renal  capsules  it  is  usually  present,  and  lastly  as 
an  expression  of  sympathy  of  the  stomach  with  a  morbid  state  of 
the  whole  system  at  the  onset  of  acute  disease,  as  exanthems,  &c. 
Each  of  these  conditions  produces  peculiar  and  characteristic  symp- 
toms, but  all  of  them  may  be  accompanied  by  violent  and  most  dis- 
tressing vomiting,  and  unless  care  be  taken  in  the  investigation  it 
may  obscure  the  primary  malady. 

But  not  only  does  the  stomach  itself  become  functionally  affected 
by  peripheraHrritation,  but  we  find  that  true  disease  of  the  stomach 
leads  to  sympathetic  disturbance  of  other  viscera,  as  of  the  head, 
causing  pain,  disturbed  vision,  muscas  volitantes,  throbbing  in  the 
head  and  ears,  tinnitus  aurium  ;  the  hepatic  and  renal  secretions  may 
be  similarly  affected ;  and  as  it  has  been  justly  observed  by  Dr.  Philip, 
these  secondary  conditions  may  become  so  severe  as  to  be  more  per- 
sistent and  trying  than  the  disease  of  the  stomach  itself;  thus  intense 


i  « 


'Gastric  Crisis  in  Locomotor  Ataxia,"  by  Dr.  Grainger  Stewart,  'Medical  Times 
and  Gazette,'  Oct.  7,  1876  ;  Charcot,  'Lesons  sur  les  Maladies  du  Systeme  Nerveux.' 
Tome  ii,  2e  edition,  p.  32. 
15 


226  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

neuralgic  pain  in  the  face  and  head  may  liave  its  source  primarily 
in  the  stomach,  and  in  functional  disease  connected  with  an  irritable 
state  of  the  pneumogastric  nerve  we  find  that  first  one  then  another 
set  of  branches  may  be  involved.  Acute  asthma  gives  place  to  irri- 
tation of  the  stomach,  and  vice  versa;  excessive  irritation  of  the  heart 
may  also  follow,  or  laryngeal  spasrn. 

An  equally  marked  association  of  disease,  arising  from  the  state 
of  the  nervous  system,  is  the  irritation  of  the  lungs  from  disturbance 
of  the  stomach  equally  with  that  of  the  stomach  in  consequence  of 
mischief  in  the  lung;  thus  dyspepsia  gives  rise  to  dyspnoea,  and  to 
cough,  from  the  irritation  of  the  gastric  branches  of  the  pneumogastric, 
producing  reflex  irritation;  so  also  with  the  heart,  by  means  of  the 
cardiac  branches  of  the  same  nerve;  for  palpitation  or  irregular 
pulsation  may  be  due  to  gastric  disturbance,  and  may  simulate  severe 
organic  disease  of  the  heart. 

In  phthisis,  it  has  been  long  noticed,  that  indigestion  may  precede 
the  physical  signs  of  disease  in  the  lungs ;  nausea,  loss  of  appetite, 
impaired  digestion,  furred  tongue,  pain  at  the  scrobiculus  cordis,  as 
well  as  severe  vomiting  to  which  we  have  referred,  and,  after  a  time, 
haemoptysis  and  the  general  signs  of  tubercular  disease  become  de- 
veloped. 

The  observations  of  Dr.  Theophilus  Thompson,  in  reference  to  the 
state  of  the  gums  in  phthisis — a  red  injected  line  being  produced 
along  the  margin  of  the  teeth — is  a  further  confirmation  of  the  irri- 
tated conditio'n  of  the  mucous  membrane.  This  early  state  of  phthi- 
sis is  that  in  which  the  greatest  benefit  is  derived  from  prophylactic 
treatment ;  by  change  to  salubrious  or  sea  air,  by  attention  to  warmth 
and  clothing,  the  avoidance  of  night  exposure,  by  taking  cod-liver 
oil,  and  sometimes  vegetable  tonics,  the  further  progress  of  the  disease 
may  in  many  cases  be  warded  off'. 

The  irritability  of  the  stomach  induced  by  functional  disturbance 
of  the  uterus  is  sometimes  excessive,  so  that  any  substance  is  instantly 
rejected ;  leucorrhcea  and  dysmenorrhcea  may  be  the  cause  of  this 
excitable  condition;  and  these  symptoms  may  exist  without  pro- 
ducing any  emaciation  in  the  patient.  It  is  to  this  condition  that 
Sir  Plenry  Marsh  has  given  the  name  of  "  regurgitative  disease,"  in 
which  the  food  or  the  greater  part  of  it  is  regurgitated  rather  than 
vomited;  and  this  takes  place  without  previous  nausea,  or  progres- 
sive emaciation;  and  pain  may  be  entirely  absent. 

In  the  treatment  of  these  forms  of  irritation  much  relief  is  afforded 
.  by  hydrocyanic  acid,  by  creasote,  by  calcined  magnesia  with  opium, 
by  chloroform  or  chloric  ether,  or  by  nitrate  of  bismuth  with  coniurn. 
Morphia  may  be  used  hypodermically,  and  in  uterine  irritation  opiate 
enemata  or  suppositories  are  often  of  great  value.  The  oxalate  of 
cerium  is  another  remedy  which  is  sometimes  of  great  service  in 
this  reflex  irritability  of  the  stomach.  Small  blisters  applied  to  the 
scrobiculus  cordis  or  to  the  spine,  sometimes  alleviate  the  symp- 
toms. 

When  the  symptoms  result  from  pregnancy,  the  mineral  acids 
will  often  aft'ord  relief,  or  the  oxalate  of  cerium  just  mentioned.  In 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  227 

this  condition  of  excessive  irritability  it  is  often  advisable  to  omit 
all  medicine,  and  allow  the  stomach  to  rest,  employing  nutrient  ene- 
mata,  and  giving  only  a  teaspoonful  of  water  occasionally  to  relieve 
thirst.  Another  plan  may  be  followed,  of  giving  a  small  quantity 
of  milk  and  water  every  ten  minutes  or  half  hour. 

In  some  instances  a  determined  effort  of  the  will  will  overcome  the 
gastric  irritation ;  the  viscus  has  become  so  irritable  that  the  least 
distension,  or  it  may  be  voluntary  pressure  at  the  scrobiculus  cordis, 
suffices  to  cause  instant  rejection  of  the  contents  of  the  stomach;  but 
the  presence  of  a  stranger  or  the  absence  of  any  vessel  into  which 
the  patient  may  vomit  may  check  the  action  ;  as  in  a  young  patient 
in  Guy's  Hospital,  who  was  cured  because  the  nurse  did  not  give  her 
any  vessel  into  which  she  might  vomit. 

Calomel  is  used  by  some  as  a  sedative  to  the  mucous  membrane 
of  the  stomach ;  but  since  this  condition  of  irritability  is  so  fre- 
quently found  associated  with  an  anaemic  and  chlorotic  or  hysterical 
state,  the  administration  of  mercurials,  except  as  occasional  aperients, 
is  better  avoided. 

A  form  of  dyspepsia,  which  primarily  arises  from  the  condition  of 
the  nervous  system,  has  been  already  noticed  in  reference  to  deficient 
secretion  of  gastric  juice  ;  namely,  the  dyspepsia  in  hypochondriasis, 
and  in  an  overworked  or  imperfectly  developed  brain  ;  this  condition 
is  exceedingly  distressing  to  the  patient,  and  equally  trying  to  the 
physician ;  it  is  sometimes  the  precursor  of  epilepsy  or  of  mania. 
In  these  instances  of  dyspepsia  the  whole  attention  is  occupied  by 
the  diet,  the  mind  is  depressed,  and  its  energies  enfeebled;  one 
change  after  another  is  tried,  but  pain  and  discomfort  equally  follow: 
the  stomach  is  sometimes  exceedingly  irritable ;  the  bowels  are 
watched  with  undue  anxiety,  the  sleep  is  unrefreshing,  and  life 
rendered  miserable.  To  tell  the  patient  nothing  is  the  matter,  would 
be  to  drive  him  to  some  one  who  would  give  an  opinion  more  in 
unison  with  his  feelings.  By  carefully  regulating  the  diet  and  the 
bowels,  by  cold  sponging,  by  taking  frequent  exercise,  either  walk- 
ing or  on  horseback,  or  a  pedestrian  tour  when  it  is  possible,  by 
keeping  the  mind  free  from  anxiety,  and  by  cheerful  society  and 
occupation,  all  the  symptoms  may  be  greatly  relieved. 

In  some  men  we  'observe  a  state  closely  resembling  hysteria ;  as 
shown  by  flatulence,  loss  of  appetite,  sensibility  of  the  surface  of  the 
abdomen,  sensations  almost  amounting  to  globus  hystericus,  dis- 
turbed cerebral  function,  depression,  anesthesia,  incapacity  for  exer- 
tion, &c. ;  in  this  condition,  which  is  often  combined  with  distension 
of  the  colon,  I  have  found  marked  benefit  result  from  the  use  of  aloes 
combined  with  steel  and  with  assafcetida;  fresh  air  and  vigorous 
exercise  are  important  remedial  agents  when  they  can  be  attained. 

In  other  cases  much  resembling  those  just  mentioned,  the  head  is 
badly  formed,  and  the  forehead  is  narrow ;  the  body  is  well  nour- 
ished, but  the  patient  complains  of  pain  at  the  scrobiculus  cordis 
and  in  the  back,  or  in  various  parts  of  the  body :  the  mind  is  de- 
pressed, and  the  appetite  irregular.  Although  muscular,  a  man 
may  be  quite  incapacitated  for  exertion;  the  tongue  may  be  clean, 


228  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

the  bowels  regular,  the  evacuations  normal  or  pale,  the  pulse  tolera- 
bly full,  or  depressed  and  irregular.  It  would  seem  that  dyspepsia 
has  arisen  from  ordinary  causes,  but  the  sympathetic  nerve  reacts 
upon  the  cerebro-spinal  centres,  and  these  being  easily  disturbed 
from  their  healthy  balance,  again  react  upon  the  sympathetic  nerve, 
perpetuating  and  aggravating  the  original  and  slighter  malady.  In 
this  we  find  the  close  connection  between  dyspepsia  or  disordered 
chylopoietic  viscera,  and  mental  disease,  mania,  and  melancholia. 

By  acting  freely  on  the  bowels  so  as  thoroughly  to  unload  the 
colon,  and  by  the  steady  perseverance  in  the  milder  preparations  of 
iron,  this  state  may  be  greatly  relieved;  the  mind  should  be  occu- 
pied and  some  out-door  exercise  should  be  enjoined;  continental 
travel  or  a  sea  voyage  will  often  prove  of  great  value,  for  nothing  is 
of  greater  disadvantage  than  to  allow  the  mind  to  prey  upon  itself, 
and  to  be  absorbed  with  its  own  morbid  sensations. 

Disease  of  the  nervous  system  is  also  associated  with  morbid  states 
of  the  appetite.  There  may  be  a  state  of  anorexia,  or  loss  of  appe- 
tite; we  do  not  refer  to  the  loss  of  appetite  seen  in  acute  disease,  nor 
in  general  exhaustion  from  chronic  or  other  disease,  but  to  those  cases 
in  which  food  is  refused,  or  gradually  lessened  till  only  a  little  bread 
and  water  may  be  taken;  some  of  these  are  instances  of  religious 
melancholia,  others  are  cases  of  cerebral  disease,  in  which  the  will 
is  at  fault  rather  than  the  stomach,  and  to  this  group  belong  the 
vaunted  instances  of  young  women  surviving  for  months  without 
food — hysterical  deception.  The  appearance  of  these  patients  is 
characteristic,  sometimes  anasmic  and  blanched,  in  other  cases  with 
haggard  expression,  wasted  features,  sunken  eye,  dressed  in  a  manner 
as  if  to  assume  great  sanctity,  the  chest  and  abdomen  wasted  to  an 
extreme  degree,  the  mind  agitated  with  extravagant  notions  or  per- 
verse delusion,  the  bowels  confined,  the  uterine  functions  in  women 
disturbed.  Most  of  these  cases,  as  Sir  Wm.  Gull  has  justly  said,  are 
diseases  of  the  mind,  and  require  treatment  directed  to  the  cerebral 
functions,  in  others  kindness  with  firmness  will  enable  the  nervous 
system  to  overcome  the  objection  to  food,  the  will  resumes  its  control 
over  the  emotions,  and,  as  a  proper  diet  is  taken,  the  nervous  system 
works  in  a  healthy  and  vigorous  manner.  Aloes,  steel,  assafoetida, 
valerian,  are  remedies  which  are  of  service,  but  these  are  of  no  avail 
unless  accompanied  with  proper  diet  and  healthful  exercise. 

Of  a  somewhat  different  character  are  those  cases  of  anorexia 
where  disease  of  the  uterus,  amenorrhoea,  and  dysmenorrhcea  have 
produced  functional  disturbance  of  the  stomach ;  food  may  cause  pain 
and  vomiting ;  the  appetite  is  gradually  lessened,  and  one  thing  after 
another  is  left  off;  the  increasing  weakness  renders  the  stomach  still 
more  enfeebled,  digestion  becomes  a  painful  process,  and  great  ex- 
haustion may  be  produced.  In  these  instances  the  patients  require 
encouragement,  and  may  be  assured  that,  as  they  gain  strengtht  the 
stomach  will  become  less  irritable  and  the  pain  will  also  1< 
Mild  chalybeates  in  effervescence  are  often  of  value,  with  a  nourishing 
and  vegetable  diet. 

Another  form  of  anorexia  is  that  which  follows  irritability  of  the 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  229 

stomach  after  ulceration ;  whether  of  a  chronic  or  superficial  kind. 
The  patient  has  left  off  one  article  of  diet  after  another,  and  the 
system  has  become  so  weakened  that  appetite  is  entirely  lost.  Ex- 
treme emaciation  is  found  in  these  cases;  they  resemble  cancerous 
disease  or  still  existing  ulceration,  but  by  careful  management,  and 
encouraging  the  patient  to  persist  in  taking  suitable  food,  although 
a  part  may  be  rejected,  the  nervous  system  gains  power :  chalybeates, 
with  gentle  laxatives,  are  often  of  value  in  these  instances. 

The  last  form  of  nervous  affection  of  the  stomach  to  which  I  have 
to  refer  is  perverted  appetite,  bulimia.  It  is  not  necessary  to  remark 
on  the  habits  of  some  insane  patients,  who  will  swallow  stones  and 
even  things  of  an  offensive  character,  but  to  other  states  of  functional 
disease.  In  diabstes  we  have  craving,  connected  not  only  with  the 
state  of  the  nervous  system,  but  with  the  condition  of  the  whole 
organism;  other  instances  often  occur  in  which  there  is  a  sense  of 
craving  at  the  stomach,  sometimes  connected  with  excessive  secretion 
of  the  gastric  juice,  to  which  we  have  already  referred,  but  in  other 
instances  patients  will  complain  that  soon  after  a  meal  they  experi- 
ence a  craving  appetite ;[  there  is  no  pain,  no  evidence  of  sugar  in 
the  urine,  no  symptoms  of  cerebral  disease,  but  the  body  is  wasted 
and  badly  nourished,  although  abundant  supplies  of  food  are  intro- 
duced into  the  stomach.  These  instances  are  connected  with  over- 
strained nervous  energy,  and  the  system  generally  requires  rest  and 
change,  and  mere  medicine  is  only  a  very  partial  benefit,  Ammonia, 
opium,  and  valerian  may  be  of  some  service. 

IY.  The  impeded  movements  of  the  stomach  are  not  sufficiently 
considered  as  causes  of  dyspepsia.  In  hernia,  when  the  omentum  is 
fixed  and  the  stomach  is  dragged  from  its  position,  pain  in  the  hy- 
pochondrium  is  produced ;  and  the  habit  of  tight  lacing,  which  few 
young  ladies  are  willing  to  admit,  is  a  fertile  source  of  the  same  suffer- 
ing; in  most  cases  the  mischief  is  done  very  early  in  life,  the  ribs 
are  scarcelv  allowed  to  expand,  and  the  stomach  is  gradually  tilted 
into  a  vertical  position  whilst  development  is  taking  place.  Neural- 
gic pain  in  the  side,  flatulent  distension  of  the  stomach,  pain  after 
food,  spasm,  borborygmi,  hysteria,  are  the  usual  sequences  of  this 
folly.  Digestion  requires  that  the  nutriment  should  slowly  revolve 
within  the  stomach,  and  as  it  is  converted  into  chyme,  that  it  should 
pass  into  the  duodenum.  When  the  stomach  is  placed  vertically,  its 
semi-digested  contents  are  more  likely  to  be  impelled  at  once  into  the 
pylorus.  In  the  modern  dress  of  ladies  the  suspension  of  the  weight 
of  the  clothes  from  the  waist  often  leads  to  interference  with  the 
functional  activity  of  the  abdominal  viscera,  and  is  a  fertile  source 
both  of  dyspepsia  and  dysmenorrhcea. 

The  dyspepsia  which  is  so  common  in  those  who  spend  many  hours 
over  the  desk,  in  writing,  or  in  reading,  or  in  any  constrained  posi- 
tion, is  of  the  same  kind;  and  amongst  tailors,  shoemakers,  dress- 
makers, &c.,  this  unnatural  and  long-continued  posture  is  productive 
of  severe  indigestion,  which  is  increased,  in  many  cases,  by  irregular 
and  intemperate  habits. 

Constant  pain  at  the  scrobiculus  cordis  and  between  the  shoulders 


'230  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

is  complained  of;  eructations  sometimes  distress  the  patient;  the 
bowels  are  often  constipated;  the  tongue  is  furred,  and  the  mind 
depressed.  We  may  often  do  much  to  remove  the  disease  by  enforc- 
ing an  erect  posture  during  the  hours  of  occupation,  by  strict  atten- 
tion to  diet,  by  well  "regulating  the  bowels,  by  relieving  torpor  of 
ihe  liver,  and,  if  needful,  by  administering  mild  alteratives,  or  nitric 
acid  with  taraxacum. 

In  tumors  developed  in  the  lesser  omentum,  or  about  the  pancreas, 
&c.,  the  pylorus  becomes  pressed  upon,  and  a  free  passage  is  pre- 
vented ;  in  this  case,  also,  we  find  pain  and  heartburn,  and  sometimes 
the  obstruction  is  sufficient  to  produce  vomiting. 

In  other  instances,  the  movements  of  the  stomach  are  prevented 
by  the  presence  of  fluid  in  the  peritoneal  cavity;  in  ascites  and  in 
ovarian  dropsy  the  stomach  may  be  so  much  pressed  upon,  that  ex- 
pansion cannot  take  place,  and  its  contents  may  be  rejected  .or  severe 
pain  may  be  produced. 

It  is  probable  that  in  some  cases  of  over-distension  from  flatus, 
the  muscular  coat  of  the  stomach  is  unable  to  contract,  or  becomes 
paralyzed.  Dr.  W.  Philip  gives  such  as  his  opinion  ;  and  cases  are 
not  very  rare  in  which,  after  death,  we  find  the  stomach  occupying 
nearly  the  whole  of  the  abdomen,  reaching  nearly  to  the  pubes,  and 
apparently  causing  death,  by  interfering  with  the  action  of  the  dia- 
phragm and  of  the  heart.  Lesser  conditions  doubtless  arise,  and  are 
attended  with  much  discomfort,  as  a  sense  of  distension,  flatus,  and 
sometimes  of  intense  pain.  The  symptoms  are  relieved  by  ether,  by 
antispasmodics,  by  the  gum  resins,  as  galbanum.  assafcetida,  &c. 

It  must  be  borne  in  mind,  however,  that  this  tympanitic  state 
sometimes  arises  from  inflammation  coming  on  insidiously,  and  in- 
volving the  muscular  as  well  as  the  peritoneal  coats,  as  in  some  cases 
of  strumous  peritonitis.  I  have  seen  several  such  instances,  in  which 
fatal  results  followed  without  any  pain  from  the  commencement  to 
the  close.  A  short  time  ago,  a  policeman  complained  of  fulness  of 
the  abdomen,  which  gradually  became  tympanitic,  but  no  pain  was 
produced;  this  state  increased  for  six  weeks,  with  prostration;  about 
a  fortnight  before  death  the  tympanitis  was  less,  and  fluctuation 
indistinct.  He  gradually  sank,  about  ten  weeks  from  the  commence- 
ment of  the  illness,  but  he  suffered  no  pain  throughout.  There  was 
chronic  peritonitis,  the  whole  serous  membrane  being  studded  over 
with  whitish  grains  of  lymph.  There  were  bands  of  adhesion,  and 
the  peritoneum  contained  several  pints  of  bloody  serum.  The  serous 
investment  of  the  spleen  was  a  quarter  of  an  inch  in  thickness,  and 
contained  small  opaque  cheesy  masses.  The  small  intestines  were 
matted  together,  but  not  very  firmly,  and  the  ileum  presented  several 
passive  ulcers.  In  the  lungs,  at  the  left  apex,  was  puckering  and 
iron-gray  consolidation.  We  might  readily  mistake  such  cases  for 
ordinary  dyspepsia  with  flatulence,  since  they  occur  in  youth  as  well 
as  in  middle  life.  These  latter  cases  must  be  distinguished  from  the 
great  distension  of  the  stomach  which  we  have  described  as  connected 
both  with  pyloric  disease  and  with  paralysis  of  the  muscular  fibre  of 
the  stomach. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  231 

V.  The >.  fermentation  of  the  contents  of  the  stomach,  and  the  symp. 
toms  consequent  upon  it,  are  due  partly  to  an  abnormal  state  ol  the 
secretions,  in  part  to  the  muscular  movements  being  impeded,  or  the 
pylorus  obstructed,  and  sometimes  to  the  character  of  the  food  itself. 
Dr.  Budd  has  distinguished  several  varieties  of  fermentation:  so  also 
Dr.  Turnbull.  1.  The  formation  of  carbonic  acid,  as  in  ordinary 
fermentation.  2.  The  formation  of  sarcina  ventriculi.  3.  Lactic  or 
butyric  acid  fermentation;  and,  4.  The  formation  of  sulphuretted 
hydrogen  by  simple  putrefactive  decomposition. 

When  the  pylorus  is  obstructed  by  cancerous  disease,  by  spas- 
modic contraction,  and  by  tumors,  the  contents  of  the  stomach  are 
prevented  from  passing  onwards;  the  viscus  becomes  distended  bv 
flatus;  pain  is  produced;  and  vomiting,  which  affords  partial  relief 
to  the  patient,  generally  follows  a  few  hours  after  food  has  been 
taken  ;  the  ejected  matters  are  found  partially  dissolved,  and  under- 
going fermentation  ;  they  have  a  sour  smell,  and  a  yeastlike  surface; 
this  action  is  allied  to  simple  fermentation ;  alcohol  is  formed,  and 
carbonic  acid  evolved ;  some  acetic  acid  is  produced ;  and  the  sarcina 
ventriculi  discovered  by  Mr.  Goodsir  are  often  detected.1 

Fermentation  of  this  kind,  and  the  presence  of  the  sarcina,  may 
exist  without  any  pyloric  obstruction  or  organic  disease;  and  sarcinae 
have  been  detected  in  the  urine,  in  the  feces,  in  pus,  in  pulmonary 
abscess,  and  on  the  healthy  mucous  membrane ;  Robin  even  states, 
"  ce  ve'ge'tal  semble  etre  sans  action  nuisible  sur  Tanimal  qui  le  porte." 
Fermentation  may  be  favored  by  the  imperfect  mastication  of  food, 
and  by  taking  exercise  immediately  after  it ;  by  drinking  fermenting 
or  new  malt  liquors;  by  indigestible  vegetables,  and  fruit;  by  new 
bread,  salads,  &c.  Distension  is  felt  almost  at  once,  and  regurgita- 
tion  of  food  into  the  oesophagus,  eructation,  palpitation  of  the  heart, 
&c..  take  place ;  colic  is  often  produced,  and  sometimes  diarrhoea,  by 
the  continuance  of  the  fermentation,  or  by  the  presence  of  semi- 
digested  substances  in  the  intestine. 

In  the  more  severe  cases  arising  from  obstruction  the  sulphite  or 
hyposulphite  of  soda,  as  recommended  by  Sir  Wm.  Jenner,  is  a 
valuable  remedy;  the  sulphurous  acid  is  set  free,  and  checks  the 
fermentative  action.  Charcoal  has  the  same  effect,  so  also  carbolic 
acid  and  creasote.  The  spasmodic  pain  from  distension  is  relieved 
by  sulphuric  or  chloric  either,  by  chloroform  or  by  opium.  In  the 
more  easily  remediable  cases  arising  from  fruits,  vegetable,  or  undi- 
gested food,  an  emetic  or  purgative  may  be  given,  and  may  be 
advantageously  followed  by  ipecacuanha  and  capsicum,  or  by  the 
nitre-hydrochloric  acid  with  calumba,  cascariila,  or  gentian.  These 
medicines  apparently  increase  the  secretion  of  the  gastric  juice  or 
improve  the  tone  of  the  mucous  surface;  but  after  the  immediate 
relief  of  the  urgent  symptoms  the  most  likely  plan  to  afford  perma- 
nent benefit  is  to  change  the  diet  to  such  substances  as  the  stomach 
can  easily  digest. 

Another  form  of  chemical  change  described  is  that  which  takes 

1  The  Merismopaedia  Ventrieuli  of  Robin,  PI.  xii,  fig.  1,  p.  331. 


232  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

place  from  the  fermentation  of  starchy  elements,  milk,  &c.,  and  which 
leads  to  the  formation  of  lactic  or  butyric  acid ;  severe  heartburn  is 
pro  luced  with  pain  at  the  stomach  and  between  the  shoulders,  some- 
times with  vomiting,  but  without  distension  ;  the  pain  is  occasionally 
very  severe  and  persistent,  even  after  vomiting ;  there  is  often  a 
sour,  nauseous  taste  in  the  mouth,  and  there  may  be  spasmodic 
attacks,  or  even  alarming  collapse.  The  state  is  much  relieved  by 
creasote,  carbolic  acid,  opium,  bismuth,  or  by  magnesia  and  hydro- 
cyanic acid. 

In  infants  the  most  severe  collapse  ensues  from  the  coagulation  of 
milk  in  the  stomach,  and  the  patient  may  be  utterly  prostrate,  as  if 
suffering  from  perforation  of  the  intestine  or  from  cholera ;  if  re- 
covery take  place,  small  masses  of  casein  and  fatty  matter  are  some- 
times passed  from  the  intestine. 

An  infant  about  a  year  old  was  seized  with  sudden  collapse  shortly 
after  being  fed,  deathly  prostration  followed,  and  it  was  believed  by 
the  parents  that  the  child  was  poisoned ;  the  flour,  milk,  water,  £c., 
of  whi'ch  the  food  had  consisted,  were  carefully  analyzed  by  my 
friend  Dr.  Odling,  and  pronounced  normal.  The  infant  became  cold, 
and  was  apparently  in  severe  pain ;  its  eyes  were  sunken,  and,  after 
a  few  hours,  several  masses  of  cheesy  substance,  about  half  an  inch 
in  length,  were  passed ;  these  I  carefully  analyzed,  and  they  were 
found  to  consist  of  oily  matter  and  casein ;  and  the  symptoms  arose 
from  milk  coagulated  in  the  stomach  having  passed  into  the  duode- 
num in  a  solid  form.  Such  at  least  was  my  diagnosis  of  the  case ; 
and  the  rapid  recovery  of  the  little  patient  showed  the  correctness 
of  the  opinion. 

In  some  persons  affected  with  dyspepsia  the  breath  becomes  ex- 
ceedingly offensive,  almost  of  the  odor  of  sulphuretted  hydrogen, 
being  similar  to  that  caused  by  carious  teeth,  diseased  tonsils,  or 
ulcerated  nares.  This  state  is  due  to  the  putrefactive  decomposition 
of  food  retained  and  undigested  in  the  stomach ;  it  is  associated 
generally  with  vitiated  secretions ;  there  is  headache,  mental  depres- 
sion, the  tongue  is  furred,  a  sense  of  uneasiness  at  the  stomach  comes 
on,  or  pain  in  the  bowels ;  the  evacuations  are  sometimes  dark  and 
unusually  offensive,  or  there  is  slight  diarrhoea.  It  would  appear 
that,  to  some  extent,  effects  similar  to  those  observed  when  sulphur- 
etted hydrogen  is  respired  are  the  result  of  this  state,  and  that  the 
blood  itself  is  contaminated  by  the  absorption  of  gas  from  the  ali- 
mentary canal.  Putrefactive  decomposition  may  also  arise  in  ob- 
structive disease  at  the  pylorus. 

In  cases  where  no  obstruction  exists,  it  is  well  to  prescribe  a  warm 
saline  aperient,  as  sulphate  of  soda,  and  the  potash  tartrate  with 
aromatic  spirit  of  ammonia;  again,  rhubarb,  soda,  and  calumba,  or 
the  compound  gentian  mixture,  may  be  advantageously  given.  Crea- 
sote tends  to  check  the  decomposition,  but  its  employment  is  less 
suitable  in  these  than  in  previously  mentioned  instances. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  233 


H^EMATEMESIS. 

There  are  several  symptoms  of  disease  of  the  stomach  which  de- 
mand separate  notice,  and  the  first  of  these  to  which  we  shall  allude 
is  haematemesis,  or  vomiting  of  blood. 

Great  alarm  is  naturally  excited  by  the  rejection  of  blood  from  the 
stomach,  whether  in  small  or  large  quantities;  but  the  import  is 
very  different,  for  whilst  in  some  cases  it  is  a  symptom  free  from 
danger,  in  others  it  is  the  indication  of  serious,  if  not  of  fatal  disease. 

The  causes  of  hasmatemesis  are — 

1st.  Ulceration  of  the  stomach. 

2d.  A  congested  or  obstructed  state  of  the  portal  circulation. 

3d.  Vicarious  menstruation. 

4th.  Cancerous  disease. 

5th.  A  vitiated  state  of  the  blood,  as  in  purpura,  renal  disease, 
yellow  fever,  typhus,  &c. 

6th.  Aneurism. 

The  hemorrhage  may,  however,  have  its  origin  in  parts  connected 
with  the  mouth,  the  throat,  and  the  oesophagus  (as  from  ulceration, 
cancerous  disease,  and  aneurism,  and  from  varicose  conditions  of  the 
cesophageal  veins1),  and  the  rejection  of  blood  from  these  sources 
may  be  erroneously  regarded  as  hsematemesis ;  or  it  may  proceed 
from  the  nose,  the  larynx,  and  the  lungs,  and  in  some  cases  consid- 
erable difficulty  arises  in  distinguishing  the  source  of  the  discharge, 
for  the  blood  may  be  swallowed  and  afterwards  vomited. 

As  to  the  quantity  of  blood  exuded,  there  may  be  the  greatest 
diversity :  sometimes  it  is  only  recognized  by  the  most  careful,  or 
even  microscopical  examination ;  it  may  be  merely  coffee-ground 
fluid ;  at  other  times  several  pints  or  even  quarts  are  rejected  at 
once ;  and  if  a  large  vessel  have  been  divided,  the  first  hemorrhage 
may  cause  fatal  syncope.  Blood  which  is  thus  discharged  into  the 
stomach  is  generally  coagulated,  and  is  often  deepened  in  color  by 
the  action  of  the  gastric  juice  ;  it  is  devoid  of  the  bright  frothy  ap- 
pearance presented  by  blood  from  the  lungs,  which  is  consequent  on 
the  admixture  of  air.  A  portion  of  the  blood  in  the  stomach  be- 
comes still  further  acted  upon  by  the  gastric  juice,  and  passes  into 
the  duodenum.  As  it  extends  along  the  small  and  large  intestine, 
the  depth  of  the  color  is  increased,  and  at  last  it  is  discharged  as  a 
pitchy,  liquid  stool,  constituting  melsena.  Sometimes  this  black 
evacuation  or  melasna  is  the  only  symptom  of  hemorrhage  into  the 
stomach,  for  no  blood  may  be  rejected  by  the  mouth ;  and  when  the 
blood  is  effused  into  the  small  or  large  intestine,  and  discharged,  the 
depth  of  the  color  is  proportionate  to  the  length  of  the  tract  through 
which  the  blood  has  passed,  but  it  never  assumes  the  black  color  to 
which  we  have  referred. 

The  green  fluid  which  is  sometimes  vomited  in  states  of  great 
irritation  of  the  stomach  has  been  regarded  by  Dr.  Fraser  as  altered 
blood  ;  and  the  coffee-ground  substance  so  often  rejected  towards  the 

1  'Schmidt's  Jahrbuch,'  1859,  Le  Diberder  und  Fauvel. 


234  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

close  of  organic  disease  of  the  stomach,  consists  also  of  blood  which 
has  slowly  exuded,  the  haernatine  being  acted  upon  by  the  gastric 
juice.  In  some  cases  of  purpura,  a  similar  appearance  is  presented 
from  a  like  cause.  Much  discussion  has  arisen  as  to  the  possibility 
of  the  transudation  of  blood  through  wnruptured  capillaries ;  but 
the  examination  of  a  portion  of  intestine  distended  with  blood,  and 
presenting  points  of  ecchymosis,  and  found  after  disease  of  the 
mitral  valve,  will  suggest  the  probable  explanation  of  instances  in 
which  blood  has  been  vomited  or  discharged,  and  in  which  no  appa- 
rent perforation  of  vessels  has  subsequently  been  found.  In  such  a 
portion  of  intestine  as  is  present  with  mitral  valve  disease,  some  of 
the  capillaries  are  found  to  be  beautifully  injected,  whilst  others  are 
collapsed,  and  blood  is  extravasated  around  them,  but  limited  by  the 
basement  membrane,  thus  constituting  a  point  of  ecchymosis ;  if  the 
basement  membrane  had  given  way,  the  blood  previously  extrava- 
sated would  have  escaped,  and  no  ruptured  vessel  would  have  been 
detected.  A  similar  action  takes  place  in  the  stomach  ;  ecchymosis 
is  produced,  but  the  action  of  the  gastric  juice  prevents  our  observing 
the  changes  with  the  same  facility  as  in  the  intestine.  There  is  little 
doubt  that  the  capillaries  thus  become  over-distended,  and  then 
ruptured  in  the  ordinary  form  of  hsematemesis,  when  no  ulceratiou 
has  taken  place.  This  statement  of  the  pathological  condition  does 
not  militate  against  the  now  generally  received  opinion  of  the  extru- 
sion of  the  blood-corpuscles  through  uuruptured  vessels. 

The  symptoms  which  precede  hasmatemesis  are  a  sense  of  faint- 
ness  followed  by  weight  at  the  scrobiculus  cordis ;  the  countenance 
becomes  pallid,  the  pulse  compressible  and  failing,  the  extremities, 
cold,  and  sometimes  actual  syncope  takes  place;  vomiting  is  then 
produced,  and  several  pints,  or  even  quarts,  of  half-coagulated  blood 
are  rejected;  the  patient  becomes  faint,  blanched,  and  the  bleeding 
is  checked.  After  a  few  days  or  hours,  there  may  be  return  of  hem- 
orrhage, till  at  last,  in  some  cases,  the  patient  appears  almost  drained 
of  blood.  The  subsequent  symptoms  are  especially  due  to  this  loss, 
as  found  in  other  instances  of  anaemia;  and  severe  headache,  noises 
in  the  ears,  disturbed  vision,  dilated  pupils,  palpitation  or  irregular 
action  of  the  heart,  with  a  sharp  but  compressible  pulse,  are  present. 
If  a  large  vessel  have  been  divided,  the  first  attack  may,  as  we  have 
before  remarked,  lead  to  fatal  syncope.  This  sudden  termination  is, 
however,  unusual ;  the  patients  slowly  rally,  and  after  a  few  hours, 
the  black,  pitchy  discharge  of  altered  blood  takes  place  from  the 
bowels. 

The  character  of  the  disease  which  has  led  to  the  hemorrhage 
must  necessarily  modify  the  preceding  as  well  as  the  general  symp- 
toms and  their  termination;  thus,  in  ulceration  of  the  stomach,  and 
in  cancerous  disease,  the  peculiar  symptoms  of  those  maladies  are 
present;  in  aneurism  a  pulsating  tumor  may  sometimes  be  felt,  and 
severe  local  pain,  or  pain  in  the  course  of  the  spinal  nerves,  may  be 
experienced.  In  a  congested  state  of  the  portal  system,  the  signs 
are  those  of  engorged  liver,  as  shown  by  pain  in  the  right  side,  dys- 
pepsia, a  sallow  or  semi-jaundiced  complexion,  furred  tongue,  occa- 


FUNCTIONAL    DISEASES    OF    THE    STOMACH/  235 

sional  nausea  or  vomiting,  impaired  appetite,  spasmodic  pain  at  the 
stomach  or  in  the  region  of  the  colon,  constipation  of  the  bowels, 
disturbed  sleep,  and  pain  in  the  head;  enlargement  of  the  liver  and 
haemorrhoids  are  also  frequently  present.  It  is  this  form  of  hemor- 
rhage that  sometimes  occurs  in  valvular  disease  of  the  heart. 

In  vicarious  menstruation,  local  congestion  of  the  mucous  mem- 
brane, or  of  the  edges  of  a  pre-excitiug  ulcer — as  we  sometimes  find 
in  an  ulcer  on  the  leg — leads  to  the  effusion  of  blood  into  the 
stomach.  In  these  cases  we  may  have  very  slight  symptoms — an 
absence  of  the  proper  menstrual  discharge,  slight  pain  in  the  side, 
and  periodical  vomiting  of  blood,  without  constitutional  disturbance, 
and  without  the  blanched  countenance  that  we  find  in  hemorrhage 
from  other  causes.  With  this  vicarious  discharge  we  not  unf're- 
quently  find  hysteria,  neuralgic  pains,  and  leucorrhcea,  &c. 

In  purpura  hernorrhagica  there  is  a  blanched  countenance,  faint- 
ness,  &c.,  but  we  have  an  indication  of  the  cause  in  the  changed 
character  of  the  blood,  as  shown  by  effusion  into  the  mucous  mem- 
brane and  into  the  skin.  The  haernatine  is  probably  acted  upon, 
and  the  corpuscles  broken  down,  so  that  actual  exosmosis  of  colored 
serum  takes  place. 

During  the  course  of  fever,  hemorrhage  from  the  bowels,  appa- 
rently of  a  critical  character,  occasionally  takes  place ;  the  patient, 
who  may  be  in  a  state  of  great  prostration,  with  a  dry  and  brown 
tongue,  rapidly  improves,  and  hence  the  discharge  of  blood  has  been 
regarded  by  some  as  indicating  a  "  crisis"  in  the  disease.  In  the  few 
cases  of  profuse  hemorrhage  which  have  come  within  the  sphere  of 
our  own  observation,  the  effusion  of  blood  has  probably  taken  place 
from  ulcerated  surfaces;  in  one,  presently  to  be  detailed,  minute 
ulcers  were  found  in  the  stomach,  from  which  a  profuse  and  fatal 
hemorrhage  occurred ;  in  another  instance,  a  young  woman,  whilst 
prostrate  from  typhoid  fever,  suffered  from  hemorrhage  to  a  great 
extent  from  the  bowels;  the  patient  became  blanched,  the  pulse  for 
many  hours  could  scarcely  be  felt,  but  very  slowly  she  completely 
recovered.  These  cases  resemble  those  in  which  very  minute  quan- 
tities of  blood  are  detected  on  microscopical  examination  of  the 
evacuations  during  typhoid  fever,  but  must  be  distinguishe  1  from 
the  hemorrhages  described  by  Dr.  Kennedy  as  occasionally  taking 
place  during  typhus  without  ulceration,  and  followed  by  rapid  re- 
covery. We  have  known  hemorrhage  from  the  stomach  to  occur 
both  in  lardaceous  disease  of  the  viscera  and  in  chronic  renal  mis- 
chief; possibly  from  degeneration  of  the  vessels,  as  has  been  de- 
scribed by  Charcot1  as  occurring  in  the  vessels  of  the  brain,  and  by 
Lionville  in  the  retina.2 

When  blood  is  poured  out  from  the  oesophagus  or  mouth,  it  is  re- 
gurgitated or  rejected  without  effort,  rather  than  vomited,  and  we 
generally  find  either  dysphagia  or  ulceration  of  the  throat,  &c. 

The  blood  from  the  lungs  is  sometimes  so  retained  in  a  vomica  or 

1  Brown-Sequard,  'Archives  de  Physiologic,'  18G8. 

2  'Gazette  des  Hopitaux,'  1870,  p.  141. 


236  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

dilated  bronchus,  that  it  loses  its  frothy  appearance  and  florid  color, 
and  the  patient  is  often  scarcely  able  to  tell  us  whether  he  vomited 
or  coughed  it  up ;  no  actual  cough  may  be  produced,  but  the  blood 
may  easily  be  brought  up  into  the  throat  and  then  spat  out,  or  it 
may  be  swallowed  and  then  vomited,  or  discharged  by  the  bowels ; 
in  these  cases  we  attach  much  importance  to  the  general  signs  of 
disease,  and  to  the  physical  examination  of  the  lungs  and  heart. 

As  to  the  prognosis  in  hemorrhage  from  the  stomach,  we  must  bear 
in  mind  that  it  is  rare  for  a  patient  to  die  from  simple  hasmatemesis, 
although  such  cases  occur ;  patients  appear  to  be  almost  bloodless, 
but  steadily  convalesce.  Still  tbe  cause  of  the  symptom  must  be  our 
guide  as  to  its  termination;  sudden  and  large  bleedings  after  symp- 
toms of  organic  disease  should  always  be  regarded  with  alarm,  for 
ulceration  often  extends  into  the  larger  arteries,  and  the  dense  fibrous 
tissue  prevents  contraction  of  the  adjoining  parts,  and  thus  the  hem- 
orrhage persists  unchecked. 

As  to  the  treatment  when  bleeding  takes  place  from  ulceration  or 
cancerous  disease,  the  use  of  styptics  is  advisable — alum  with  dilute 
sulphuric  acid,  acetate  of  lead,  gallic  acid,  catechu,  tincture  of  iron, 
or  oil  of  turpentine,  may  be  used;  but  in  cases  where  it  arises  from 
congestion  of  the  liver,  I  have  generally  looked  upon  the  haemate- 
mesis  as  to  a  great  extent  curative,  and  have  prescribed  remedies 
calculated  to  relieve  the  congested  liver,  as  a  grain  or  two  of  blue 
pill  with  conium,  and  magnesia  mixture,  in  order  to  remove  the 
effused  blood  from  the  intestines. 

Ice  and  cold  drinks  are  grateful  to  the  patient,  and  beneficial  in 
producing  contraction  of  bleeding  vessels ;  but  food  should  be  ab- 
stained from,  because  coagula  may  be  removed  by  it  from  divided 
vessels,  and  hemorrhage  may  be  again  produced.  After  a  short 
time,  fluid,  demulcent  nourishment  can  be  given,  but  it  should  be 
in  a.  nearly  cold  condition  ;  and  when  there  is  evidence  of  a  cessation 
of  the  hemorrhage,  solid  substances,  easy  of  digestion,  may  be  taken 
in  small  quantities.  Vegetable  tonics  with  mineral  acids,  and  the 
milder  preparations  of  steel,  will  then  be  found  of  service ;  but  we 
shall  be  often  much  disappointed  by  the  various  astringents,  as  gallic 
acid,  alum,  &c.,  which  afford  only  partial  relief;  oil  of  turpentine,  in 
doses  of  "Ixx,  has  been  much  recommended,  and  has  been  followed 
by  beneficial  results ;  its  stimulant  as  well  as  astringent  effects  have 
been  well  marked. 

It  is  exceedingly  important  that  the  patient  should  avoid  those 
habits  or  excesses  which  have  led  to  the  disease,  but  advice  on  this 
subject  is  generally  disregarded. 

In  vicarious  menstruation,  our  efforts  should  consist  in  endeavor- 
ing to  establish  the  proper  and  natural  discharge,  rather  than  imme- 
diately to  check  that  which  proceeds  from  the  stomach,  unless  it  be 
excessive.  Hip  baths,  steel,  aloes  and  myrrh,  change  of  air,  exercise, 
the  avoidance  of  tight  lacing  or  unnatural  excitement,  will  probably 
restore  the  health,  but  this  form  of  hasmatemesis  will  sometimes  con- 
tinue for  a  considerable  period. 

In  purpura,  the  preparations  of  steel  with  acids  are  generally  the 


FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

best  remedies  that  we  can  use,  as  the  tincture  of  the  sesqui chloride 
or  the  sulphate  of  iron,  with  sulphuric  acid;  the  oil  of  turpentine 
also  is  sometimes  of  great  value,  although  its  taste  may  offend  the 
palate. 

CASE    LXXIX.      Hcematemesis  from   Cancer  of  the  Liver The  most 

marked  case  of  haematemesis  and  makena  from  this  cause  that  I  have  ever 
witnessed  was  in  a  man  about  55  years  of  age ;  he  was  in  an  emaciated  con- 
dition, cachectic,  and  semi-jaundiced ;  the  liver  was  enlarged,  and  it  was 
believed  that  he  suffered  from  cancerous  disease  of  that  organ,  a  diagnosis 
which  was  found  after  death  to  be  correct.  He  was  suddenly  seized  with 
violent  vomiting  of  blood,  and  black  stools  were  passed.  In  about  eight 
hours  he  died.  On  inspection,  we  found  cancerous  disease  of  the  liver  ;  there 
was  no  ulceration  in  the  stomach,  nor  evidence  of  any  ruptured  vessel ;  the 
intestine  contained  a  considerable  quantity  of  blood  ;  but  no  ulcer.  On  open- 
ing the  vena  portse,  it  was  found  that  the  cancerous  disease  had  extended  into 
the  vessel,  and  completely  occluded  it,  and  that  softened  cancerous  matter  was 
injected  along  the  branches  of  the  vena  portae,  so  as  completely  to  check  the 
circulation.  The  cause  of  the  luematemesis  was  at  once  apparent — the  capil- 
laries of  the  stomach  had  become  suddenly  engorged  with  blood,  and  had 
ruptured,  leading  to  the  fatal  hemorrhage ;  but  no  openings  nor  ruptured 
vessel  could  be  found,  for  the  distension  had  disappered,  and  the  minute 
vessels  had  collapsed.  A  similar  result  is  found  in  many  instances  of  vomit- 
ing of  blood  after  intemperance. 

CASE  LXXX.  Hcematemesis  from  Portal  Congestion. — James  P — ,  aet. 
45,  residing  at  Milton  Street,  was  admitted  into  Guy's  Hospital,  February 
2d,  1859.  He  was  a  man  of  intemperate  habits,  and  whilst  at  work  some 
time  previously,  packing  hay  and  exerting  his  strength,  sickness  and  flatu- 
lence came  on,  and  he  vomited  about  a  pint  and  a  half  of  grumous  blood,  and 
afterwards  smaller  quantities  of  clear  blood.  He  was  under  treatment  for 
fourteen  days,  and  then  returned  to  his  work.  From  that  time  he  had  had 
pain  across  his  chest,  which  sometimes  moved  to  the  epigastrium  with  much 
flatulence.  Three  weeks  beforf  admission,  immediately  after  jumping  to 
reach  a  handle  above  him,  he  vomited  up  half  a  gallon  of  brown -colored  blood 
in  clots ;  and  some  blood  passed  per  rectum.  When  brought  to  Guy's  he 
had  a  yellowish  semi-jaundiced  complexion,  and  suffered  from  pain  at  the 
scrobiculus  cordis  ;  the  lungs  were  healthy  ;  the  pulse  was  full,  soft,  80  ;  the 
tongue  coated  :  the  appetite  defective  ;  the  bowels  open  ;  the  urine  not  albu- 
minous. He  was  ordered  infusion  of  roses  with  acid,  and  milk  diet.  4th. — 
There  was  slight  pain,  no  return  of  vomiting,  but  he  had  j  assed  blood  by  the 
bowels ;  the  tongue  was  furred.  8th — He  appeared  nearly  well,  and  was 
soon  afterwards  presented. 

This  case  of  hsematemesis  probably  arose  from  bepatic  engorge- 
ment, due  to  intemperance ;  and  the  hemorrhage  from  the  over-con- 
gested mucous  membrane  of  the  stomach  was  in  itself  curative. 

CASE  LXXXI.  Hcematemesis  after  great  Intemperance — Alfred  W— , 
set.  38,  admitted  into  Guy's  under  my  care  in  May,  1855,  was  a  tall  man  per- 
fectly blanched  in  appearance,  and  on  admission  he  was  almost  in  a  state  of 
syncope.  He  had  been  for  some  time  a  porter  at  the  Brighton  Railway,  and 
had  drunk  very  freely  of  spirits,  although  accustomed  to  eat  but  little  food. 
During  the  Epsom  races,  having  harder  work  than  usual,  he  drank  still  more 
intemperately  ;  he  had  been  troubled  with  occasional  pain  at  the  stomach, 


238  .FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

and  with  vomiting.  The  day  before  admission  he  felt  a  sense  of  weight  at 
his  stomach,  which  he  tried  to  relieve  by  taking  more  spirits  ;  a  feeling  of 
faintness  came  over  him,  and  he  vomited  several  pints  of  dark-colored  blood. 
lie  was  much  excited  on  admission,  and  there  was  considerable;  tremor  of  the 
hands.  The  skin  was  moist,  the  tongue  and  lips  pale,  the  bowels  confined. 
The  liver  was  much  enlarged,  and  there  was  slight  tenderness  at  the  scro- 
biculus  cordis. 

There  was  evidence  in  this  case  of  great  engorgement  ol  the  portal 
system,  and  although  some  additional  hemorrhage  took  place  I 
adopted  the  plan  of  endeavoring  to  relieve  the  distended  liver,  and 
constipated  bowels,  rather  than  of  administering  styptics.  Blue  pill 
and  conium  were  given,  and  magnesia  mixture.  In  this  way  black 
blood,  acted  upon  by  the  gastric  and  intestinal  secretions,  was  dis- 
charged, and  the  patient  rapidly  improved.  The  hemorrhage  re- 
turned slightly  on  the  third  day,  probably  from  spirits  surreptitiously 
obtained.  He  steadily,  however,  convalesced;  food  was  given  as  he 
could  take  it,  and  afterwards  steel  medicine. 

Most  of  these  cases  arise  from  the  rupture  of  over  distended  capil- 
laries, rather  than  from  ulceration,  and  we  may  generally  give  a  very 
favorable  prognosis.  Where  ulceration  exists,  and  arteries  are  per- 
forated by  the  disease,  a  fatal  result  sometimes  ensues;  several  cases 
of  this  kind  are  recorded  with  ulceration  of  the  stomach,  in  one  of 
which,  although  fatal  hemorrhage  took  place,  nearly  all  the  blood 
passed  into  the  duodenum,  and  scarcely  any  was  vomited.  Death, 
however,  does  occasionally  follow  without  any  ulceration  being  de- 
tected. 

CASE  LXXXII.  Hcematempsis,  vicarious  Menstruation,  aggravated 
Hysteria,  simulating  Fever — Mary  H — ,  a?t.  19,  was  admitted  into  Guy's 
under  my  care  in  May,  1855.  She  liad  enjoyed  good  health  till  she  was  six- 
teen years  of  age,  when  she  said  that  she  had  a  convulsion  followed  by  ''brain 
lever  ;"  and  on  recovery  began  to  vomit  blood  three  days  successively  at  her 
regular  monthly  periods  ;  if  this  did  not  occur  she  had  pain  between  the 
shoulders,  at  the  epigastrium,  and  dyspnoea  ;  this  vomiting  of  blood  continued 
regularly  for  three  years,  but  she  never  menstruated  properly.  For  nine 
months  the  discharge  had  ceased  altogether,  and  three  months  before  admis- 
sion she  had  a  severe  hysterical  or  epileptic  tit. 

On  admission  she  appeared  stout,  tolerably  nourished,  but  prostrate  ;  the 
tongue  was  dry  and  brown,  and  almost  black  ;  she  lay  motionless  in  bed, 
without  speaking,  and  altogether  refused  food,  sometimes  groaning,  and  if 
taken  from  her  bed  appeared  to  fa;nt.  She.  complained  of  pain  at  the  lower 
part  of  the  back,  and  in  the  inguinal  region  ;  the  abdomen  was  tympanitic 
and  distended  i  she  stated  that  surgeons  had  twice  removed  clots  of  bloo.l 
from  her;  but  my  friend  and  colleague,  Dr.  Oldham,  could  find  no  enlarge- 
ment nor  disease  of  the  uterus,  and  believed  that  an  attempt  had  been  made 
to  divide  the  os  uteri.  She  refused  to  swallow  food;  the  pulse  was  feeble  and 
very  quick.  There  was  sliirhtly  increased  antero-posterior  curvature  of  the 
spine  in  the  lower  part  of  the  dorsal  region. 

Milk  was  poured  into  the  mouth,  and  she  was  made  to  swallow  it ;  in  this 
way  a  considerable  quantity  of  food  was  taken. 

Galhamim  and  zinc  with  aloes  and  myrrh  were  prescribed,  and  the  bowels 
were  thoroughly  cleared  by  blue  pill  with  colocynth  and  henbane,  and  by 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  239 

enemata  of  rue  or  soap.  Local  depletion  was  used  from  the  groins  by  the 
application  of  leeches,  and  afterwards  quinine  and  steel  were  given  with  wine, 
and  sparks  of  electricity  were  taken  from  the  spine  ;  a  shower  batli  was  occa- 
sionally used. 

The  stomach  retained  food,  and  the  patient  soon  became  able  to  walk,  and 
left  the  hospital  in  a  few  weeks  convalescent. 

This  was  one  of  the  most  severe  cases  of  hysteria  that  we  ever 
witnessed  ;  and  the  disturbance  of  the  stomach  and  alimentary  canal 
were  no  doubt  produced  by  the  functional  disease  of  the  uterus, 
aggravated  by  treatment  which  I  think  few  obstetricians  would 
approve  of.  The  vicarious  discharge  of  blood  from  the  stomach  was 
not  observed  during  the  period  she  was  in  the  hospital,  but  it  is 
received  on  the  testimony  of  the  patient  and  her  friends. 

CASK  LXXXIII.       Vicarious  Menstruation    from    the  Stomach Ellen 

H — ,  set.  23,  was  admitted  under  my  care  into  Guy's  Hospital,  August  28th, 
1860.  She  was  a  needlewoman,  who  had  resided  at  Kingsland,  and  she  had 
for  several  years  been  in  feeble  health,  complaining  of,  pain  at  the  chest  and 
palpitation  of  the  heart,  &c.  Menstruation  commenced  when  she  was  eighteen 
years  of  age,  but  the  function  had  been  irregularly  per  brmed,  sometimes 
ceasing  for  four  to  eight  months.  For  six  months  prior  to  admission  she  had 
vomited  blood  at  her  menstrual  periods,  but  occasionally  she  had  menstruated 
regularly,  and  no  haematemesis  then  took  place  ;  before  the  attacks  of  hemor- 
rhage, and  for  several  days  before  menstruation,  she  had  pain  at  the  stomach 
and  in  the  right  side,  loss  of  appetite,  and  nausea;  the  vomiting  of  blood  then 
came  on  and  continued  for  several  days.  She  was  a  spare,  and  somewhat 
anremic  woman,  with  an  anxious  expression  of  countenance,  and  rather  dark 
complexion  ;  her  S3-mptoms  were  those  of  amenorrlicea  with  dyspepsia  ;  and 
during  the  time  that  she  remained  in  the  hospital  she  complained  of  pain  at 
the  scrobiculus  cordis,  and  sometimes  also  at  the  right  side,  and  the  pain 
was  increased  by  food  ;  there  was  occasional  nausea,  but  no  vomiting ;  the 
bowels  were  regular.  Her  general  health  was  improved  by  preparations  of 
steel  and  quinine,  with  a  carefully  regulated  diet ;  but  during  the  time  she 
was  in  the  hospital  there  was  neither  return  of  hemorrhage  trom  the  stomach, 
nor  was  menstruation  established.  She  continued  under  my  care  as  an  out- 
patient, and  was  afterwards  re-admitted,  sutfering  still  from  dyspepsia;  but 
she  had  had  no  return  of  hemorrhage.  The  dyspepsia  was  again  relieved. 

In  this  case  there  was  probably  ulceration  of  the  stomach,  and  we 
regard  a  periodical  congestion  of  the  mucous  surface,  and  consequent 
rupture  of  minute  capillary  vessels,  as  the  cause  of  the  repeated 
hemorrhage.  Although  during  the  time  the  patient  was  under  ob- 
servation there  was  no  hsematemesis,  we  have  no  reason  to  doubt 
her  very  positive  assertion  that  for  several  months  she  vomited 
blood  at  the  ordinary  period  of  menstruation,  and  the  discharge  was 
in  that  respect  evidently  vicarious.  Normal  menstruation  has  since 
been  established,  and  has  continued  regularly,  but  she  has  suffered 
occasionally  from  severe  dyspepsia. 

CASE  LXXXIV.  Typhus  Fever.  Hcematemesis. — Ann  M — ,  set.  19,  a 
hawker  on  the  streets,  was  admitted  into  Guy's  Hospital,  February  2  1,  1859, 
and  died  February  4th.  Fever  exited  in  the  house  where  she  lived,  and 
she  had  been  ill  for  nine  davs.  When  brought  to  the  hospital  she  had  tl.e 


240  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

symptoms  offerer,  with  great  depression,  and  with  mottling  and  lividity  of 
the  skin  ;  still  she  was  rational.  On  the  evening  of  the  4th,  the  eleventh 
day  of  fever,  vomiting  of  blood  took  place,  and  was  passed  per  rectum  ;  in 
a  few  hours  she  died. 

On  inspection  the  lungs  were  healthy  ;  the  heart  was  firm  but  empty  ;  the 
stomach  was  full  of  blood,  and  at  the  lesser  curvature  there  were  several 
minute  depressions  or  erosions  affecting  only  the  surface,  and  not  penetrating 
the  entire  thickness  of  the  membrane;  one,  a  little  deeper  than  the  rest,  ap- 
peared to  have  a  minute  vessel  at  the  base  ;  but  this  fact  could  not  be  satis- 
factorily established.  The  duodenum  was  reddened  and  congested,  and  blood 
was  found  in  both  the  jejunum  and  ileum,  and  the  colon  was  also  full  of 
blood.  No  ulceration  nor  disease  of  the  intestine  was  found;  the  spleen  was 
large  and  soft,  but  the  mesenteric  glands,  as  well  as  the  liver  and  kidneys, 
were  healthy. 

This  instance  of  hemorrhage  could  not  be  regarded  as  precisely 
analogous  to  those  which  sometimes  occur  when  the  character  of  the 
blood  is  changed,  as  in  yellow  fever,  purpura,  &c.,  for  erosions  ex- 
isted in  the  stomach  from  which  the  blood  escaped ;  but  the  pros- 
tration of  fever  doubtless  rendered  the  hemorrhage  more  persistent, 
and  perhaps  had  an  important  influence  in  determining  the  minute 
ulcerations.  The  patient  was  about  the  age  at  which  perforating 
ulcer  sometimes  occurs.  In  her  case,  the  loss  of  blood  led  to  a  rapid 
fatal  issue. 

PAIN  AS  A  SIGN  OF  DISEASE  OF  THE  STOMACH. 

The  two  symptoms  which  are  regarded  as  especially  indicative  of 
disease  of  the  stomach  are,  perhaps,  more  than  any  other  liable  to 
mislead ;  we  refer  to  vomiting  and  to  pain  in  the  region  of  the 
stomach ;  and  we  shall  briefly  enumerate  the  causes  from  which 
these  symptoms  proceed  as  the  best  safeguard  against  error.  The 
explanation  of  the  uncertain  diagnostic, value  of  these  symptoms  is 
found  first,  in  the  intimate  connection  of  the  nerves  of  the  sympa- 
thetic plexus  with  all  the  abdominal  viscera  and  with  the  spinal 
nerves ;  and,  secondly,  in  the  extensive  distribution  of  the  pneumo- 
gastric  nerve,  which  supplies,  in  the  abdomen,  not  only  the  stomach, 
but  the  duodenum,  the  liver,  the  pancreas,  the  kidney,  and  the  supra- 
renal capsule  ;  and,  in  the  chest,  the  same  nerve  extends  to  the  lungs 
and  respiratory  tubes,  and  communicates  with  the  cardiac  ganglia. 
And,  again,  it  is  frequently  found  that  irritation  of  one  set  of 
branches  of  nerves  manifest  itself  in  the  disturbed  function  of  another 
part  supplied  by  the  same  nerve,  and  that  disease  at  the  central 
origin  of  the  nerve  is  shown  at  the  peripheral  branches ;  thus,  pain 
in  the  ear  is  produced  by  a  decayed  tooth,  the  branches  of  the  fifth 
pair  of  nerves  supplying  both  the  tooth  and  the  ear ;  disease  at  the 
origin  of  the  pneumogastric  nerve  in  the  brain,  or  of  the  pulmonary 
branches,  is  often  manifested  by  a  disturbed  condition  of  the  fila- 
ments supplied  to  the  stomach,  and  vomiting  is  the  result. 

As  a  sign  of  disease  pain  is  of  doubtful  value :  oftentimes  it  is  a 
certain  guide  to  the  locality,  if  not  to  the  character  of  the  morbid 
action ;  at  other  times,  on  the  contrary,  its  presence  misleads,  or  its 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  241 

absence  disposes  us  to  underestimate  changes  which  may  be  going 
on  in  the  system.  Generally  speaking,  we  find  that  the  mucous 
membranes,  except  where  they  approach  the  outlets  of  their  respec- 
tive canals,  are  free  from  ordinary  sensibility,  and  may  undergo 
very  marked  changes  in  their  condition  without  any  painful  mani- 
festation. Acute  disease  may  take  place  in  the  mucous  membrane 
of  the  small  or  large  intestine,  in  the  mucous  membrane  of  the 
kidney  or  bladder,  with  complete  immunity  from  suffering.  A 
similar  fact  is  observed  in  relation  to  the  parenchymatous  viscera ; 
thus  the  substance  of  the  .liver  or  the  kidney  is  often  changed  in  a 
marked  degree ;  and  if  disease,  such  as  an  abscess,  forms  in  their 
structure  without  much  distension,  the  patient  may  be  unconscious 
of  morbid  change.  On  the  contrary,  in  serous  membranes  an  oppo- 
site condition  is  found  to  exist,  almost  any  change  is  appreciated, 
and  in  sudden  or  acute  disease  the  pain  is  often  extremely  severe  in 
its  character.  We  well  know  the  stabbing  pain  of  pleurisy,  the 
agony  of  acute  peritonitis,  and  the  intense  suffering  of  severe  syno- 
vitis.  In  each  of  these  latter  diseases  rest  is  a  very  essential  ele- 
ment in  the  alleviation  of  the  malady,  and  this  rest  can  be  attained 
to  a  great  extent  without  the  cessation  of  life.  In  pericarditis,  on 
the  contrary,  we  find,  as  for  many  years  shown  by  Dr.  Addison, 
that  there  is  an  absence  of  pain,  unless  there  be  pleurisy  occurring 
at  the  same  time ;  for  in  the  pericardium,  however  desirable  rest 
may  be,  movement  must  continue  as  long  as  life  lasts. 

In  reference  to  pain  as  an  indication  or  non-indication  of  disease 
we  have  to  remark — 

I.  That  acute  inflammation  and  disease  of  the  stomach  may  exist, 
with  entire  freedom  from  pain,  if  the  mucous  membrane  only  be 
affected.  Acute  gastritis  is  generally  regarded  as  an  exceedingly 
rare  form  of  disease,  excepting  when  produced  by  irritant  poisons. 
This  may  be  the  case ;  but  we  are  of  opinion  that  in  many  instances 
the  absence  of  pain  has  led  to  this  belief.  In  the  gastro-enteritis  of 
children,  and  not  very  unfrequently  in  that  of  more  advanced  life, 
conditions  of  great  irritability  with  cessation  of  the  right  functions 
of  the  stomach,  and  probably  with  hyperaemia,  must  be  regarded  as 
closely  approaching  the  character  of  gastritis.  However  this  may 
be,  we  have  evidence  from  the  action  of  irritant  poisons  that,  while 
the  mucous  membrane  only  is  affected  by  them,  pain  may  be  entirely 
absent,  excepting  that  consequent  on  the  violent  muscular  action 
exerted  in  the  act  of  repeated  vomiting.  Thus  in  a  patient  who  had 
taken  a  large  dose  of  oxalic  acid,  violent  vomiting  was  produced, 
with  failing  pulse,  and  a  sense  of  exhaustion,  but  no  pain.  In  a  few 
days  after  taking  demulcent  forms  of  diet,  she  completely  recovered. 
In"an  instance  of  poisoning  by  sulphuric  acid,  in  which  a  large  por- 
tion of  the  mucous  membrane  of  the  stomach  was  destroyed,  and 
although  the  patient  survived  eleven  days,  she  did  not  appear  to 
suffer  from  any  pain  at  the  stomach.  The  same  fact  was  still  more 
strikingly  shown  in  an  instance  in  which  chloride  of  zinc  had  been 
taken;  life  was  prolonged  for  three  months;  the  absence  of  suffering 
was  remarkable  till  eight  days  before  death ;  and  the  pam  then,  we 
16 


242  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

do  not  doubt,  was  due  to  the  formation  of  an  abscess  in  the  left  hy- 
pochondriac region.  I  have  witnessed  the  same  immunity  from 
suffering  in  poisoning  by  arsenic,  and  by  corrosive  sublimate ;  and 
we  are,  I  think,  warranted  in  the  belief  that  acute  disease  may  take 
place  in  the  mucous  membrane  of  the  stomach  without  any  pain. 

II.  Organic  disease  of  the  mucous  membrane,  as  for  instance  cancer, 
may  be  comparatively  free  from  pain.     It  frequently  happens  iu 
cancerous  disease  of  the  liver,  that  after  death  tubercles  or  growths 
of  similar  character  are  observed  on  the  mucous  membrane,  and  of 
which  there  had  been  no  indication  during  life.     Thus,  a  patient 
aged  sixty,  who  died  from  cirrhosis,  and  in  whom  after  death  a  large 
villous  growth  was  found  attached  to  the  anterior  surface  of  the 
stomach,  although  the  orifices  were  free,  made  no  complaint  of  any 
pain  at  the  stomach,  neither  was  there  any  vomiting;  and  it  is 
probable  that  the  burning  pain  she  had  before  admission  was  of  the 
character  often  observed  in  ordinary  dyspepsia,  for  she  was  of  intem- 
perate habits.     The  freedom  from  any  obstruction  at  the  orifices,  and 
the  growth  involving  only  the  mucous  membrane,  were,  we  think, 
the  causes  of  the  absence  of  pain.     No  supposition  was  entertained 
of  the  presence  of  this  growth  in  the  stomach  during  life. 

III.  Disease  extending  to  the  muscular  or  peritoneal  coats  pro- 
duces generally  severe  pain,  as  observed  in  ordinary  ulceration  or 
cancer.     This  symptom  is  present  as  one  of  the  most  ordinary  signs 
of  the  conditions  just  mentioned,  often  coming  on  directly  after  food 
has  been  taken.     In  several  instances,  in  which  the  suffering  was 
exceedingly  intense,  we  have  found  branches  of  the  pneumogastric 
nerve  involved  in  the  thickened,  dense,  and  fibrous  edges  of  the 
ulcer.     In  a  case  of  this  kind  which  I  watched  with  much  interest, 
the  cause  of  death  was  gradually  increasing  exhaustion,  as  the  con- 
sequence of  the  intense  pain  and  constant  vomiting.     It  was  a  young 
woman  aged  twenty -one,  who  suffered  from  constant  and  severe  pain, 
with  progressive  emaciation,  continuing  for  many  months,  unrelieved 
by  the  administration  or  application  of  any  anodyne  that  we  possess. 
A  month  before  death  symptoms  of  acute  phthisis  came  on ;  and,  at 
the  inspection  a  large  chronic  ulcer  was  found  at  the  lesser  curvature, 
and  several  branches  of  the  pneumogastric  nerve  were  traced  to  the 
edges  of  the  ulcer,  and  some  passing  across  its  base  were  only  covered 
by  fibrous  tissue. 

IV.  Over-distension  of  the  stomach  produces  severe  pain.     The 
formation  of  the  stomach  and  its  peritoneal  attachments  are  such  as 
to  allow  of  moderate  distension  in  the  performance  of  ordinary  diges- 
tion ;  but  whenever  the  distension  becomes  greatly  increased,  pain 
is  the  result. 

Y.  Disease,  especially  of  an  acute  kind,  affecting  the  peritoneum, 
is  also,  with  few  exceptions,  accompanied  by  severe  pain.  In  refer- 
ence, however,  to  the  position  of  the  pain  in  peritonitis,  it  is  not 
always  a  certain  guide  to  the  precise  seat  of  injury.  A  young  woman, 
under  the  care  of  the  late  Dr.  Golding  Bird,  was  seized  with  sudden 
severe  pain  at  the  scrobiculus  cordis  and  towards  the  left  side,  fol- 
lowed by  rapid  collapse ;  from  the  seat  of  the  pain  perforation  of  the 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  243 

stomach  was  diagnosed ;  it  was,  however,  found  to  be  perforation  of 
the  appendix  caeci. 

VI.  Dr.  Osborne  has  shown,  that  in  some  cases  of  gastric  ulcer 
the  position  which  gives  the  greatest  ease  to  the  patient  may  serve 
as  a  guide  to  the  exact  seat  of  the  disease  ;  that  if  the  ulcer  be  on  the 
posterior  surface,  lying  upon  the  face  would  be  the  most  comfortable 
position,  and  vice  versa.  Food,  on  its  entrance  into  the  stomach, 
generally  passes  directly  along  the  lesser  curvature;  and  if  the  viscus 
be  contracted,  it  would  come  in  contact  with  an  ulcer,  whether  placed 
on  the  anterior  or  posterior  aspect  of  the  median  line  of  the  curva- 
ture. If  more  distended,  there  might  be  less  direct  application  to 
the  diseased  surface ;  in  the  case  of  severe  suffering  from  gastric 
ulcer  previously  referred  to,  the  patient  appeared  to°be  most  easy 
when  leaning  somewhat  forward  and  towards  the  left  side,  which 
would  have  the  effect  of  allowing  fluids  to  gravitate  from  the  ulcer, 
as  mentioned  by  Dr.  Osborne.  We  have  seen  several  cases  which 
tend  to  confirm  this  opinion. 

YII.  In  disease  of  the  lesser  curvature,  near  the  pyloric  orifice, 
pain  is  sometimes  experienced  by  the  patient  as  soon  as  the  food 
enters  the  stomach,  and,  in  some  cases,  this  conveys  the  idea  of  dis- 
ease at  the  cesophageal  orifice.  This  fact  may  lead  to  the  supposition 
that  the  oesophagus  is  the  part  affected,  and  the  opinion  may  be 
strengthened  by  the  rejection  of  food  almost  before  it  has  reached 
the  stomach. 

VIII.  Many  conditions  of  functional  disease  are  entirely  free  from 
pain.     It  is,  indeed,  well  for  us  that  there  is  such  insensibility,  other- 
wise the  least  deviation  from  healthy  action  might  be  followed  by 
suffering,  and  the  strict  rules  of  a  dyspeptic  would  be  essential  in 
ordinary  life. 

IX.  The  pain,  in  many  functional  diseases  of  the  stomach,  is  ex- 
ceedingly severe ;  but  it  is  often  produced  by  a  mal-condition  of  the 
nerves  or  nerve-centres,  and  it  arises  from  the  intimate  connection 
of  the  spinal  and  sympathetic  nerves.     In  some  states  of  exhaustion 
the  whole  of  the  nervous  system  appears  to  be  in  a  state  of  great 
irritability,  and  the  sensibility  of  structures  becomes  greatly  increased. 
We  often  find,  in  these  conditions,  that  the  stomach  is  incapable  of 
bearing  the  presence  of  food;    it  is  at  once  rejected,  or  produces 
intense  pain,  or  flatulent  distension  ensues,  or  a  sense  of  fainting; 
and  the  means  best  calculated  to  relieve  are  those  which  invigorate 
and  strengthen  the  whole  system.     Of  this  class  are  the  stomach 
diseases  observed  in  connection  with  uterine  disease,  with  loss  of 
blood,  exhaustion,  mental  anxiety,  &c.     The  deficient  nervous  supply 
also  interfering,  perhaps,  with  the  right  secretion  of  gastric  juice. 

X.  The  effect  of  a  diseased  condition  of  the  pneumogastric  nerve 
at  its  centre,  or  at  its  peripheral  branches,  in  connection  with  stom- 
ach disease,  is  of  great  interest,  and  it  is  probable  that  pain  is  some- 
times the  result.     We  have,  however,   more  frequently  observed 
vomiting  rather  than  pain  produced  by  an  irritable  condition  of  the 
pneumogastric  nerve. 

XI.  In  some  forms  of  functional  disease  of  the  stomach,  in  which 


244  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

severe  pain  comes  on  three  or  four  hours  after  food,  it  is  probable, 
as  we  have  elsewhere  stated,  that  extreme  irritability  of  the  pyloric 
orifice  exists. 

XII.  In  functional,  as  in  organic  disease,  pain  often  arises  from 
distension  of  the  stomach,  consequent  on  chemical  decomposition  of 
the  alimentary  mass. 

-  XIII.  The  absence  of  pain  sometimes  arises  from  the  destruction 
of  the  pneumogastric  nerve.  This  fact  was  remarkably  shown  in  a 
patient  suffering  from  sloughing  at  the  extremity  of  the  oesophagus; 
and  in  cancerous  disease  of  the  stomach  the  same  thing  has  been 
observed. 

XIV.  Pain  at  the  scrobiculus  cordis,  simulating  disease  of  the 
stomach,  often  arises  from  spinal  disease,  the  pain  being  referred  to 
the  extremity  of  the  irritated  nerve. 

XV.  Severe  pain  at  the  scrobiculus  cordis  is  frequently  present  in 
chronic  bronchitis  and  in  obstructive  valvular  disease  of  the  heart ; 
in  fact,  from  any  state  which  leads  to  over-distension  of  the  cavities 
on  the  right  side  of  the  heart.     In  these  conditions  we  very  gene- 
rally find  that  food  produces  pain  and  flatulence,  and  is  very  imper- 
fectly digested ;  the  vessels  of  the  stomach  and  of  the  whole  of  the 
chylopoietic  viscera  are  much  engorged,  and  the  surface  of  the  stom- 
ach is  very  generally  covered  with  a  thick  layer  of  mucus,  a  state 
of  chronic  catarrh  of  the  gastric  mucous  membrane  being  produced. 
Many  observers,  however,  attribute  the  almost  constant  pain  at  the 
scrobiculus  cordis  in  these  instances  to  the  over-filled  cavities  of  the 
right  side  of  the  heart,  and  we  are  disposed  to  refer  part  of  the  dis- 
tress to  this  cause. 

XVI.  In  aneurism  of  the  abdominal  aorta  we  have  sometimes 
observed  pain  of  a  most  intense  kind,  and  the  disease  might  very 
readily  have  been  mistaken  for  cancerous  disease  of  the  stomach 
with  glandular  infiltration,  producing  pressure  upon  the  aorta.     In 
one  instance,  which  I  watched  with  much  interest,  the  aneurism 
existed  at  the  position  of  the  cceliac  axis ;  it  was  rightly  diagnosed, 
and  the  patient  became  exhausted  f  nd  died  from  the  intensity  of  the 
pain,  the  false  sac  not  having  given  way.    I  dissected  large  branches 
of  the  sympathetic  nerve  spread  out  upon  the  surface  of  the  tumor ; 
and  the  intense  suffering  and  fatal  exhaustion  appeared  to  arise  from 
the  implication  of  the  nerve  structures ;  no  qther  cause  of  death 
could  be  found  on  very  careful  inspection. 

Enough  has  been  said  to  show  that  the  most  careful  investigation 
of  this  symptom  is  necessary  in  order  to  form  a  correct  diagnosis  of 
disease  of  the  stomach. 

VOMITING  AS  A  SIGX  OF  DISEASE. 

The  causes  of  vomiting  are  still  more  varied  than  those  of  pain 
at  the  stomach ;  and  the  importance  of  carefully  estimating  these 
causes  is  in  proportion  to  their  complexity ;  and  although  some  of 
them  are  not  connected  with  gastric  disease,  we  still  make  brief 
reference  to  them.  They  may  be  divided  into  those  which  originate 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  245 

in  the  stomach  and  intestines,  and  secondly,  into  those  which  arise 
from  alteration  in  the  nervous  supply  elsewhere,  either  central  or 
peripheral. 

In  the  first  division  we  must  place — 

1.  Inflammation  of  the  stomach  ;  gastritis  and  gastro-enteritis. 

2.  Undigested  food,  or  foreign  bodies  in  the  stomach. 

3.  Irritants  and  medicines. 

4.  Great  irritability  of  the  mucous  membrane. 

5.  Ulceration  of  the  stomach. 

6.  Obstructive  disease  of  the  pylorus. 

7.  Cancerous  disease. 

8.  Acute  peritonitis. 

9.  Pressure  on  the  stomach,  as  in  acites  and  ovarian  dropsy,  in 
abdominal  tumors,  &c. 

10.  Diseases  of  the  duodedum. 

11.  Hernia,  intestinal  obstruction,  intussusception. 

12.  Pharyngeal  and  oesophageal  regurgitatiou. 

In  the  second  division  are — 

1.  Diseases  of  the  liver  and  gall-bladder. 

2.  Diseases  of  the  kidney. 

8.  Diseases  of  the  suprarenal  capsules. 

4.  Diseases  of  the  uterus  and  ovaries. 

5.  Diseased  conditions  of  the  blood  and  general  nervous  system, 
as  at  the  onset  of  exanthems,  fevers,  pyaemia,  erysipelas,  &c. ;  ague, 
yellow  fever,  and  cholera  may,  perhaps,  be  classed  among  these  as 
arising  from  blood  change. 

6.  Diseases  of  the  spine. 

7.  Diseases  of  the  brain. 

8.  Diseases  of  the  lungs. 

I.  There  is  something  remarkable  in  the  presence  of  vomiting  in 
circumstances  where  pain  is  absent ;  thus,  in  acute  disease  of  the 
stomach,  where  only  the  mucous  membrane  is  affected,  the  patient 
may  be  free  from  all  suffering  at  the  region  of  the  stomach,  except- 
ing that  produced  by  the  violent  straining  of  the  muscles  during 
vomiting.     We  need  not  do  more  than  to  refer  to  the  instances  of 
poisoning  by  oxalic  acid,  by  sulphuric  acid,  by  arsenious  acid,  and 
by  corrosive  sublimate,  which  have  been  already  given  as  illustra- 
tions of  this  fact ;  and  in  the  symptoms  of  gastro-enteritis  the  same 
immunity  from  gastric  pain  occurs,  whilst  vomiting  greatly  distresses 
the  patient. 

II.  Undigested  substances  often  remain  in  the  stomach  for  some 
time  without  producing  pain,  unless  they  pass  within  the  pyloric 
valve ;  and  we  sometimes  find  that  they  are  retained  for  many  hours 
or  even  days  before  they  are  rejected  by  vomiting. 

III.  In  reference  to  vomiting  caused  by  msdicine  and  by  irritants, 
it  is  only  necessary  to  mention  that  in  some  instances  the  action 
appears  to  be  one  of  primary  irritation  of  the  stomach,  in  others  it 
is  secondary,  through  the  medium  of  the  blood;  but  whether  this 


246  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

secondary  action  and  its  consequent  vomiting  arises  from  the  excre- 
tion of  the  medicinal  substance  from  the  mucous  membrane  of  the 
stomach  is  doubtful ;  thus  tartar  emetic  produces  vomiting  when 
injected  into  the  blood  equally  as  when  taken  directly  into  the 
stomach. 

IV.  We  have  referred,  in  our  remarks  on  functional  disease  of  the 
stomach,  to  states  of  extreme  irritability  of  the  mucous  membra n  > 
in  which  food  of  every  kind  is  at  once  rejected..    This  form  of  func- 
tional irritability  we  have  found  to  be  generally  associated  with 
uterine  and  ovarian  disease ;  or  it  has  been  produced,  apparently, 
by  irritation  of  the  pulmonary  branches  of  the  pneumogastric,  to 
which  we  shall  presently  have  to  refer ;  but  in  some  instances  we 
have  not  been  able  positively  to  trace  the  complaint  to  one  or  other 
of  these  causes,  and  at  present  we  must  acknowledge,  though  unwil- 
lingly, as  a  cause  of  vomiting,  functional  irritability  of  the  stomach 
itself.     It  is  to  this  form  of  disease  that  Sir  H.  Marsh  has  given  the 
name  of  regurgitative  disease,  in  which  food  is  rejected  ivithout  any 
effort,  and  often  without  corresponding  emaciation.     In  his  valuable 
paper  on  this  subject,  he  refers  to  its  connection  with  pulmonary  and 
with  uterine  disturbance. 

V.  In  ulceration  of  the  stomach,  vomiting  often  comes  on  as  soon 
as  food  enters  the  stomach,  or  a  period  of  variable  length  intervenes, 
the  pain  increasing  till  the  rejection  takes  place. 

VI.  In  obstructive  disease  at  the  pylorus,  the  vomiting  is  gene- 
rally deferred  till  nearly  the  close  of  the  digestive  process;  much, 
however,  may  be  done  to  diminish  this  symptom  by  the  administra- 
tion of  fluid  diet,  and  one  that  does  not  easily  undergo  fermentation, 
so  that  sometimes  several  days  elapse  between  the  attacks. 

VII.  Cancerous  disease  affecting  the  orifices  of  the  stomach  consti- 
tutes a  common  cause  of  persistent  vomiting.     It  must,  however,  be 
borne  in  mind  that  vomiting  is  not  a  constant  sign  of  cancerous  dis- 
ease of  the  stomach  ;  if  the  orifices  be  free,  it  may  be  entirely  absent, 
although  the  disease  is  very  extensive;  and  again,  if  sloughing  take 
place,  even  when  the  orifices  also  are  diseased,  vomiting  often  sub- 
sides, sometimes  in  consequence  of  the  obstruction  being  removed 
by  the  sloughing;  at  other  times,  apparently,  from  the  destruction 
of  the  branches  of  the  pneumogastric  nerve.     Further,  the  period  at 
which  vomiting  occurs  does  not  always  indicate  the  seat  of  the  can- 
cerous obstruction ;  in  some  instances  of  obstruction  at  the  pylorus, 
with  disease  at  the  lesser  curvature,  vomiting  takes  place  imme- 
diately after  food  has  entered  the  stomach,  so  as  to  convey  the  idea 
of  obstruction  at  the  cardiac  orifice  or  in  the  oesophagus  itself,  and 
the  symptom  has  been  regarded  as  dysphagia  rather  than  vomiting. 

VIII.  Acute  peritonitis,  especially  when  the  gastric  peritoneum  is 
involved,  is  often  accompanied  with  severe  vomiting.     The  state- 
ment has  been  made,  that  vomiting  does  not  take  place  in  acute 
peritonitis  unless  the  peritoneum  in  the  neighborhood  of  the  stomach 
is  implicated ;  but  although  this  is  generally,  it  is  not  constantly  the 
case.     Chronic  peritonitis  is  also  a  cause  of  vomiting ;  so  also  local 
peritonitis  and  effusion  near  the  stomach.     In  some  of  these  in- 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  247 

stances  the  stomach  is  affected  by  its  direct  implication  in  the  dis- 
ease; in  others  vomiting  arises  from  the  pressure  of  effused  pus  or 
the  constriction  of  adhesions. 

IX.  Pressure  on  the  stomach  is  a  direct  cause  of  vomiting.     In 
ciscites  and  ovarian  dropsy,  the  stomach  is  sometimes  so  compressed 
that  vomiting  comes  on  soon  after,  food  has  been  taken,  apparently 
from  this  cause  alone  ;  and  when  paracentesis  has  been  performed, 
the  pressure  being  removed,  the  sickness  ceases.     When  glandular 
tumors  in  the  neighborhood  of  the  pancreas  or  disease  of  the  pancreas 
itself  exert  pressure  on  the  stomach,  the  symptoms  closely  resamble 
primary  disease  of  the  stomach,  and  the  diagnosis  is  exceedingly 
difficult ;  but,  since  the  pancreas  receives  .a  branch  from  the  pneii- 
mogastric  nerve,  it  is  not  easy  to  ascertain  how  far  vomiting  in  some 
of  these  cases  is  due  to  nervous  irritation,  and  how  far  it°is  due  to 
direct  pressure.     In  those  cases  in  which  the  pancreas  has  baen  dis- 
eased, without    great   enlargement    and  without   pressure   on    the 
stomach  or  duodenum,  I  have  not  observed  vomiting  as  a  promi- 
nent symptom. 

In  aneurismal  disease  of  the  abdomen,  the  remark  which  we  made 
in  reference  to  disease  of  the  pancreas  and  its  glands  holds  good ; 
and  the  same  difficulty  arises  in  determining  how  far  the  vomiting 
is  due  to  pressure  or  to  sympathetic  irritation. 

In  some  cases  we  have  found  direct  pressure  made  by  the  patient 
at  the  scrobiculus  cordis  the  cause  of  vomiting ;  many  persons  can 
thus  at  once  empty  the  stomach;  and  in  an  instance  of  a  boy,  some 
years  ago,  in  Guy's  Hospital,  it  was  only  after  very  careful  watching 
that  the  true  character  of  the  complaint  and  the  deceit  of  the  patient 
was  ascertained. 

X.  As  to  vomiting  not  dependent  upon  the  condition  of  the  stom- 
ach itself,  we  have  to  refer  to  morbid  states  of  other  abdominal 
viscera,  and  first  to  disease  of  the  duodenum,  as  inflammation  of  its 
mucous  membrane,  ulceration,  and  especially  obstruction.     There  is 
great  similarity  between  the  diseased  condition  of  the  first  portion 
of  the  duodenum  and  of  the  stomach.     In  the  first  portion,  for  in- 
stance, ulceration  produces  many  of  the  symptoms  of  like  disease  in 
the  stomach.     A  form  of  dyspepsia  in  which  vomiting,  with  pain  at 
the  seat  of  the  duodenum,  comes  on  at  the  close  of  digestion  has  been 
attributed  to  the  duodenum  ;  but  whether  this  class  of  cases  is  con- 
nected with  the  abnormal  irritability  of  the  pylorus  itself,  we  cannot 
affirm.     Again,  in  some  cases  of  acute  jaundice,  febrile  symptoms 
arise  with  violent  irritability  of  the  stomach,  but  without  pain  ;  and 
the  disease  has  been  attributed  to  mischief  commencing  in  the  duo- 
denum, and  'extending  to  the  biliary  ducts.     In  some  fatal  cases  of 
this  kind,  great  congestion  in  the  duodenum  has  tended  to  confirm 
the  idea ;  so  also  the  fact,  that  these  symptoms  have  come  on  after 
intemperance. 

XI.  In  hernia,  obstructive  disease  of  the  intestines,  intussusception^ 
&c.,  vomiting  is  generallv  present.    If  the  obstruction  be  in  the  small 
intestine,   the   vomiting  comes  on  very  quickly;  but  if  the  colon, 
sigmoid  flexure,  or  rectum,  be  the  seat  of  disease,  vomiting  is  often 


248  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

postponed  for  a  considerable  time,  unless  irritant  medicines  and  vio- 
lent purgatives  have  been  administered.  As  the  vomiting  continues, 
the  ejected  matters  present  the  character  of  the  fluids  at  the  seat  of 
obstruction,  and  if  that  obstruction  be  intestinal,  their  odor  and 
appearance  have  more  or  less  of  a  fecal  character. 

XII.  The  regurgitation  of  food,  rather  than  vomiting,  which  is 
consequent  on  disease  of  the  pharynx,  larynx,  or  oesophagus,  must 
be  distinguished  from  actual  vomiting.     By  carefully  observing  the 
process  of  deglutition,  the  seat  of  mischief  may  be  accurately  ascer- 
tained.    In  paralysis  of  the  muscles  of  the  soft  palate  and  of  the 
pharynx,  deglutition  cannot  be  properly  completed,  and  food  is  re- 
jected through  the  nares ;  so  also  when  the  epiglottis  is  ulcerated 
from  strumous,  syphilitic,  or  cancerous  disease,  the  act  of  deglutition 
is  scarcely  performed  before  the  substance  swallowed  is  violently 
ejected,  and  severe  pain  in  the  throat,  and  cough,  are  set  up.     It  is 
remarkable,  too,  in  these  cases,  how  a  solid  bolus  of  food  may  be 
formed  and  swallowed,  slipping  beyond  the  diseased  surface,  whilst 
the  smallest  quantity  of  fluid  produces  most  violent  pain  and  distress. 
In  obstruction  of  the  oesophagus,  the  act  of  deglutition  being  already 
completed,  regurgitation  takes  place.     Very  extensive  disease  may, 
however,  affect  the  oesophagus  without  this  rejection  of  food  ;  for 
ulceration    or  sloughing   may   have   removed    obstruction,   or   the 
branches  of  the  pneumogastric  nerve  and  the  whole  wall  of  the  canal 
may  be  destroyed.     Vomiting  in  other  cases  is  the  manifestation  of 
the  general  and  intimate   connection  of  the   stomach   with    other 
viscera;  it  is  produced  by  reflex  irritation,  and  is  properly  desig- 
nated sympathetic  in  its  origin ;  its  study  as  a  symptom,  is  of  essen- 
tial importance  in  the  diagnosis  of  disease  of  the  stomach.     As  to 
vomiting  due  to  other  extraneous  sources  we  shall  do  little  more  than 
enumerate  them  ;  and  the  first  of  this  class  to  which  we  allude  is — 

XIII.  Disease  of  the  liver  and  of  the  gall-bladder ;  large  branches 
of  the  pneumogastric  nerve  extend  to  the  liver,  as  well  as  numerous 
nerves  from  the  large  sympathetic  ganglia.     In  gall-stone,  violent 
vomiting  is  generally  associated  with  intense  pain  ;  and  in  many, 
conditions  of  hepatic  disease  the  same  symptom  is  constantly  present. 

XIV.  In  disease  of  the  supra-renal  capsule,  vomiting  is  rarely 
absent ;  but  sometimes  it  is  a  sign  of  such  prominence  as  to  simulate 
primary  disease  of  the  stomach.     On  post-mortem  examination  we 
have  found  arborescent  injection  of  the  mucous  membrane  of  the 
stomach,  and  sometimes  slight  superficial  ulceration ;  but  it  must 
also  be  remembered,  that  the  pneumogastric  nerve  affords  a  branch 
to  the  supra-renal  capsule,  and  that  the  connection  of  the  capsule 
with  the  semilunar  ganglia  is  a  very  intimate  one. 

XV.  Diseases  of  the  kidneys  and  renal  calculus  constitute  other 
causes  of  vomiting.     During  the  passage  of  a  calculus  down  the 
ureter,  vomiting  is  a  very  distressing  symptom.     In  acute  albumi- 
nuria  vomiting  is  also  associated  with  nausea ;  and  in  chronic  albu- 
minuria  it  is  sometimes  the  precursor  of  a  fatal  termination.     So 
severe,  indeed,  may  be  this  symptom  in  ischuria  renalis,  as  even 
to  suggest  the  possibility  of  intestinal  obstruction,  as  shown  by  Dr. 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  249 

Barlow.  The  vomiting  in  albuminuria  is  not  only  due  to  the  direct 
connection  of  the  nerves  constituting  the  renal  plexus  with  those  of 
the  stomach,  but  to  the  urea  excreted  from  the  mucous  membrane 
of  the  stomach  and  intestines.  It  is  found  to  be  present  in  large 
quantity  in  the  blood,  and  is  separated  in  all  the  excretions  and 
secretions ;  and  in  the  stomach,  this  abnormal  excremeniitious  sub- 
stance appears  to  act  as  a  direct  irritant. 

XVI.  Both  functional  and  organic  diseases  of  the  uterus  and  ova- 
ries are  causes  of  vomiting.     In  dysmenorrhoea,  most  distressing 
irritability  of  the  stomach  is  occasionally  set  up ;  and  in  pregnancy, 
vomiting  may  be  so  severe  as  to  exhaust  and  completely  to  prostrate 
the  patient,  and  in  ovarian  disease,  the  gastric  symptoms  are  often 
mistaken  for  primary  disease  of  the  stomach. 

XVII.  The  remaining  causes  of  vomiting  arise  from  the  condition 
of  the  nervous  system,  and  are  most  interesting  and  important  in 
the  correct  diagnosis  of  disease ;  the  first  of  these  is  a  diseased  con- 
dition of  the  spine.    The  splanchnic  nerves  pass  from  the  spinal  cord 
to  the  large  sympathetic  ganglion  of  the  abdomen,  and  constitute  an 
intimate  connection  between  these  centres  of  nerve-force ;  in  those 
diseases,  however,  of  the  spine  in  which  we  have  observed  irrita- 
bility of  the  stomach,  other  sources  of  disturbance  have  been  present. 

XVIII.  At  the  onset  of  acute  diseases,  especially  the  exanthems, 
the  continued  fevers,  pyaemia,  erysipelas,  &c.,  vomiting  is  often  pre- 
sent.    It  is  not  known  how  this  is  produced,  whether  directly  by  the 
altered  condition  of  the  nervous  system,  or  secondarily  from  the 
state  of  the  blood.     Sudden  nervous  shock,  fright,  &c.,  will  produce 
vomiting  ;  and  in  some  more  chronic  diseases,  when  the  blood  is 
altered  in  character,  as  in  renal  disease  and  even  gout,  the  same 
symptom  is  occasionally  very  intractable. 

Dr.  Graves,  in  his  'Clinical  Medicine,'  makes  the  following  valuable 
remarks  in  reference  to  this  subject : — "  Every  fever  which  commences 
with  vomiting  and  diarrhoea,  whether  it  be  scarlatina,  or  measles,  or 
typhus,  is  a  fever  of  a  threatening  aspect ;  and  in  all  such  fevers  the 
practitioner  should  be  constantly  on  the  watch,  and  pay  the  most 
unremitting  attention  to  the  state  of  the  brain.  There  is  much  differ- 
ence between  the  vomiting  and  diarrhosa  of  gastro-enteritis,  and  this 
cerebral  diarrhoea  and  vomiting.  The  latter  sets  in  generally  at  a 
very  early  period  of  the  disease,  perhaps  on  the  first  or  second  day, 
and  is  seldom  accompanied  by  the  red  and  furred  tongue,  the  bitter 
taste  of  the  mouth,  the  burning  thirst,  and  the  epigastric  tenderness 
which  belong  to  gastro-enteric  inflammation.'1  He  also  states  very 
truly,  that  in  cerebral  disease  there  is  often  a  large  quantity  of  bile 
rejected  by  vomiting,  and  passed  also  by  stool ;  and  that  leeching 
the  abdomen  is  less  efficacious  in  cerebral  inflammation  than  in 
gastro-enteritis. 

Very  little  is  known  as  to  the  proximate  cause  of  vomiting  in 
cholera  and  in  yellow  fever;  but  we  sometimes  find  in  the  intermit- 
tents  of  our  own  country  that  vomiting  is  a  prominent  symptom ; 
and  we  have  several  tiines  witnessed  instances  in  which  vomiting, 


250  FUNCTIONAL    DISEASES    OF    THE    STOMACH. 

excited  possibly  by  uterine  or  hepatic  mischief,  assumed  regular 
periodicity  in  those  who  had  been  exposed  to  miasmatic  poison. 

A  young  person,  who  had  resided  in  a  low,  marshy  locality  in 
Cambridgeshire,  presented  this  periodicity  of  symptoms  in  a  re- 
markable degree.  She  was  a  phthisical  subject,  and  the  mucous 
membrane  was  very  irritable.  A  tertian  irritability  of  the  stomach 
and  intestines  existed ;  on  every  other  day  there  were  vomiting  and 
diarrhoea  with  coldness  and  chilliness.  Long  residence  in  a  mias- 
matic district  had  probably  given  this  periodicity  to  the  symptoms, 
and  aggravated  her  anaemic  condition. 

XIX.  Irritation  of  the  peripheral  branches  of  the  pneumogastric 
nerve  in  the  abdomen  has  already  been  referred  to  as  one  causa  of 
vomiting  in  disease  affecting  the  organs  to  which  they  are  supplied: 
but  the  same  nerve  may  be  changed  at  the  peripheral  branches  in 
the  chest,  and  at  its  origin  in  the  brain.  Disease  of  the  brain,  then, 
is  another  cause  of  vomiting,  and  one  which  it  is  important  to  bear 
in  mind  in  the  diaganosis  of  disease ;  too  often  the  so-called  bilious 
attacks  of  children  are  the  first  indications  of  acute  hydrocephalus. 
The  irritability  of  the  stomach  is  sometimes  so  great,  that  vomiting 
is  at  once  produced  when  the  patient  is  raised  from  the  recumbent 
position.  The  diagnosis  of  these  cases  is  sometimes  exceedingly 
difficult  when  commencing  with  symptoms  of  true  gastro-enteric  dis- 
ease ;  but  it  would  be  well  if  the  remark  of  the  great  authority  in 
clinical  medicine  just  quoted  were  borne  in  mind,  that,  "  in  all  fever- 
ish complaints,  where  during  the  course  of  the  disease  the  stomach  be- 
comes irritable  without  any  obvious  cause,  and  where  vomiting  occurs 
without  any  epigastric  tenderness,  you  may  expect  congestion  or  in- 
cipient inflammation  of  the  brain  or  its  membranes."  In  simple 
cerebral  disease  the  abdomen  is  generally  collapsed;  in  primary  ab- 
dominal disease  there  is,  on  the  contrary,  distension.  This  difficulty 
in  diagnosis  is  not,  however,  limited  to  very  young  subjects.  In 
strumous  disease  of  the  brain,  the  vomiting  is  sometimes  excessive, 
and  I  have  seen  it  associated  with  chlorosis  and  ausemia. 

After  concussion  of  the  brain,  vomiting  comes  on ;  and  in  some 
cases,  when  inflammatory  disease  has  followed  and  suppuration  has 
taken  place,  the  vomiting  is  excessive.  One  of  the  most  severe 
cases  of  secondary  vomiting  which  I  have  ever  witnessed  was  of  this 
kind.  A  man  in  middle  life  had  received  a  blow  at  the  back  of  the 
head ;  cerebral  symptoms  came  on,  and  suppuration  took  place  at 
the  origin  of  the  pneumogastric  nerve ;  the  membranes  were  adhe- 
rent at  that  part  for  the  space  of  half  an  inch,  and  about  half  a 
drachm  of  pus  was  effused.  The  vomiting  was  excessive;  anything 
swallowed  was  rejected  with  violence  beyond  the  extremity  of  his 
bed. 

XX.  Disease  of  the  lungs,  or  irritation  of  the  pulmonary  brandies 
of  the  pneumogastric  nerve,  is  the  last  cause  of  vomiting  to  which 
we  refer.  The  vomiting  in  whooping-cough  appears  to  be  of  this 
kind,  and  equally  so  the  vomiting  which  is  often  present  at  the  early 
stage  of  phthisis;  the  same  symptom  may  occur  in  acute  as  well  as 
in  chronic  disease  of  the  lung.  Sir  Henry  Marsh  has  mentioned 


FUNCTIONAL    DISEASES    OF    THE    STOMACH.  251 

early  phthisis  as  one  of  the  causes  of  the  irritability7  oTthe  stomach, 
to  which  he  has  given  the  naree-of  regAiFgitativexliseastK-and  -tpo 
frequently  it  leads  to  the  unfortunate  ^expression,  that  the  symptoms 
of  early  consumption  are  "all  stortiach'."  It  seems  that  as  the1  pul- 
monary disease  advances,  and  disorganization  takes  place,  this  con- 
dition of  irritability  is  lessened,  although  we  often  find  that  the  par- 
oxysms of  cough  are  productive  of  violent  vomiting. 

Many  interesting  physiological  questions  in  reference  to  vomiting 
might  have  been  dwelt  upon ;  but  sufficient  has  been  stated  to  show 
that  it  is  impossible  satisfactorily  to  diagnose  and  to  treat  disease  of 
the  stomach  without  duly  recognizing  the  value  of  each  symptom  in 
its  general  bearing;  and  further,  that  the  most  effective  manner  of 
alleviating  any  symptom,  however  distressing,  is  not  by  the  treat- 
ment of  that  symptom,  but  by  the  removal  of  its  cause. 

The  importance  cannot  be  over- estimated  of  distinguishing  be- 
tween vomiting  of  cerebral,  spinal,  or  nervine  origin,  and  that  which 
arises  from  gastric  or  other  abdominal  disease. 


252 


oiHW.e^i  ro  30  HpHJqo 

HeYHS 
CHAPTER   VII. 

DUODENUM. 

THE  symptoms  which  have  been  regarded  by  some  writers  as 
proceeding  from  disease  of  the  duodenum  have  by  others  been  re- 
ferred to  states  of  the  liver,  of  the  stomach,  or  of  the  pancreas. 

My  own  observations,  and  the  facts  which  I  adduce  in  the  following 
remarks,  show  that  there  are  symptoms  of  disease  justly  attributable 
to  this  portion  of  the  alimentary  canal;  and  that  in  some  cases  we 
may,  with  care,  satisfactorily  diagnose  that  the  duodenum  is  diseased. 
The  peculiarities  of  its  position  and  structure  deserve  our  careful 
attention.  Extending  from  the  pyloric  extremity  of  the  stomach  to 
the  jejunum,  it  is  about  twelve  inches  in  length,  and  may  be  divided 
into  three  nearly  equal  portions;  the  first  is  the  most  movable,  is 
almost  surrounded  by  peritoneum,  and  is  horizontal  in  its  direction  ; 
it  may  be  called  the  pyloric  or  stomachic  portion  of  the  duodenum, 
for  it  is  associated  with  the  stomach  in  its  diseases.  The  second  is 
vertical  in  direction,  closely  fixed  near  to  the  crura  of  the  diaphragm, 
and  to  the  venacava;  it  receives  the  common  bile  and  pancreatic 
ducts  generally  by  a  single  opening,  and  is  hepatic  in  its  morbid 
relations.  The  pancreas  is  situated  on  the  left  side  of  the  second 
portion  ;  and  the  vena  portae,  the  hepatic  artery,  and  the  branches 
of  the  pancreatico-duodenal  artery  are  also  in  relation  with  it.  The 
third  is  horizontal  in  direction,  and  is  simply  intestinal  in  its  function  ; 
the  pancreas  is  situated  above  it;  in  front  the  superior  mesenteric 
vessels  enter  the  mesentery,  and  behind  it  are  placed  the  aorta  and 
the  vena  cava.  The  three  portions  of  the  duodenum  are  situated  on 
different  planes,  the  first  portion  being  near  to  the  anterior  abdominal 
parietes,  whilst  the  third  part  is  immediately  upon  the  spine  ;  and 
this  arrangement  allows  the  contents  of  the  canal  mechanically  to 
gravitate  quickly  into  the  jejunum,  and  assists  also  the  discharge  of 
bile  from  the  ducts. 

The  muscular  layers  of  the  duodenum  are  double;  a  circular  and 
a  longitudinal  coat,  as  in  other  portions  of  the  small  intestine.  The 
mucous  coat  is  covered  with  villi,  which  commence  at  the  duodenum, 
and  soon  become  exceedingly  numerous  ;  so  also  the  valvulie  conni- 
ventes  are  gradually  developed,  till  we  find  them  as  large  as  in  the 
jejunum.  The  whole  of  the  surface  is  studded  over  with  Lieber- 
kiihn's  follicles!  ;  not  unfrequently,  especially  in  young  subjects,  there 
are  solitary  glands,  as  in  the  jejunum  and  ileum.  There  are  also  the 
glands  of  Brunner,  minute  compound  glands  peculiar  to  the  duode- 
num, and  which  are  situated  beneath  the  substance  of  the  mucous 
membrane;  these  commence  a  few  lines  from  the  pylorus,  and  extend 
about  as  far  as  the  common  bile  duct  ;  their  function  is  not  definitely 


DUODENUM.  253 

known,  but  they  are  believed  to  resemble  minute  salivary  or  pancre- 
atic glands.  It  sometimes  happens  that  the  solitary  glands  are  so 
distinct,  that  they  may  very  easily  be  mistaken  for  Brunner's  glands; 
the  latter  are,  however,  situated  beneath  the  mucous  membrane,  and 
microscopical  examination  at  once  manifests  their  difference. 

There  is  still  another  point  in  connection  with  the  duodenum  that 
deserves  consideration,  and  which  indicates  its  close  connection  with 
the  stomach  and  with  the  liver.  The  pneumogastric  nerves,  branches 
of  which  supply  the  stomach,  and  also  the  liver,  send  filaments  along 
the  first  portion  of  the  duodenum,  continued  onwards  from  the  lesser 
curvature  of  the  stomach  ;  this  associates  that  part  of  the  duodenum 
very  intimately  with  the  stomach.  Besides  this  nervous  supplv  we 
have,  according  to  the  observations  of  Meissner  and  Auerbach, 
minute  plexuses  of  nerves,  both  in  connection  with  the  mucous  and 
muscular  coats. 

The  pancreatico-duodenal  artery,  which  supplies  the  greater  part 
of  the  duodenum,  is  from  the  hepatic,  and  the  pyloric  branch  of  the 
coronary  extends  into  the  first  part  of  the  duodenum,  so  that  in  the 
arterial  supply  we  find  the  same  association. 

State,  of  secretion. — The  secretion  is  stated  to  be  alkaline,  and  such 
is  probably  the  case ;  the  acid  reaction  after  death  arising  from  the 
gastric  juice,  which  has  gravitated  through  the  pylorus.  Whether 
a  patulous,  feeble  contractile  power  in  the  pylorus,  allowing  the 
secretions  of  the  stomach  to  pass  at  irregular  periods  into  the  duo- 
denum, is  the  cause  of  the  discomforts  associated  with  these  forms 
of  dyspepsia,  we  have  no  data  on  which  to  form  an  opinion.  Cor- 
visart  states  that  the  pancreatic  fluid  discharged  into  the  duodenum 
has  the  power  of  dissolving  albuminous  substances ;  this  opinion  is, 
however,  controverted  by  Dr.  Brinton  ;  the  former  describes  duo- 
denal dyspepsia  as  arising  from  an  abnormal  condition  of  this 
secretion. 

Congenital  malformation. — The  duodenum  sometimes  has  a  double 
sigmoid  curvature — a  peculiar  arrangement  which  I  observed  in  a 
patient  who  died  from  intestinal  obstruction.  The  ascending  colon 
was  adherent  to  the  sigmoid  flexure,  and  the  caecum,  twisted  upon 
itself,  was  situated  in  the  left  hypochondriac  region.  The  person 
had  been  born  at  the  seventh  month,  and  the  cascum  was  preter- 
naturally  free. 

In  a  cyclopean  monster,  I  found  the  viscera  of  a  double  foetus  in 
a  single  peritoneal  cavity;  a  double  oesophagus  was  united  in  a 
single  stomach,  with  a  large  convexity  extending  across  the  abdo- 
men ;  and  a  single  duodenum,  placed  vertically,  received  the  biliary 
pancreatic  ducts  on  either  side. 

Diverticula  are  exceedingly  rare  as  compared  with  those  which 
arise  from  the  lower  part  of  the  ileum  ;  but  small  pouches  are  more 
frequently  present,  and  they  consist  generally  of  mucous  membrane, 
thus  constituting  a  sort  of  hernial  protrusion.  In  the  museum  of 
Guy's  is  one  of  these  situated  near  the  opening  of  the  duct  into  the 
duodenum. 

Some  believe  that  the  duodenum  becomes  distended  with  flatus,  or 


254.  DUODENUM. 

with  retained  chyme,  as  the  result  of  indigestion;  and  where  there 
is  mechanical  obstruction,  which  we  shall  afterwards  describe,  this 
may  be  the  case.  It  is  possible  also  that  an  enormously  distended 
transverse  colon  may  impede  the  free  passage  of  the  contents  of  the 
third  portion,  but  such  is  problematical.  The  distension  which  has 
been  supposed  to  arise  from  the  duodenum,  will  generally  be  found 
to  be  distension  of  the  stomach  or  the  transverse  colon  ;  for  the  duo- 
denum passes  quickly  to  a  lower  level,  and  I  believe  its  contents  at 
once  gravitate  into  the  jejunum. 

As  to  the  strictly  pathological  states,  we  find  congestion  sometimes 
active,  more  frequently  passive ;  ulceration,  cancer,  and  lastly  me- 
chanical obstruction  are  also  noticed. 

To  some  it  may  appear  altogether  futile  to  speak  of  congestion  or 
hyperaemia  of  the  duodenum,  but  observation  of  the  appearances 
after  death  convinces  me  that  marked  changes  occur,  and  that  in 
some  instances  a  careful  investigation  might  have  pointed  out  their 
existence  during  life. 

Great  congestion  of  the  duodenum  is  found  in  various  diseases  in 
which  a  similar  condition  extends  to  the  whole  tract  of  the  alimentary 
canal,  as  in  disease  of  the  mitral  valve,  and  in  portal  obstruction  in 
hepatic  disease ;  but  there  are  other  cases  in  which  we  find  active 
congestion,  especially  in  acute  pneumonia.  The  latter  state  of  acute 
hypersemia  is  illustrated  in  the  following  case  : 

CASE  LXXXV.  Inflammation  of  the  Bronchi,  of  the  Bile-Ducts,  or 
Biliary  Hepatitis,  fyc.  Acute  Congestion  of  the  Duodenum. — Thomas  H — , 
aet.  42,  was  admitted  into  Guy's  Hospital,  March,  1852 ;  he  had  been  ill  for 
three  weeks.  He  was  a  large,  stout  man,  who  for  fourteen  years  had  been 
in  the  police  service ;  his  habits  of  life  had  been  very  intemperate.  Four 
years  previously  he  had  received  a  severe  blow  in  his  right  side  from  a  prize- 
fighter, and  for  some  time  he  had  been  subject  to  vomiting  in  the  morning, 
and  the  bowels  had  at  times  been  much  relaxed ;  before  admission  jaundice 
came  on  ;  he  had  had  more  anxiety  of  mind  than  usual,  and  gradually  be- 
came languid  and  icteric.  For  four  days  his  legs  had  swollen,  afterwards  his 
abdomen,  and  his  strength  became  prostrated.  The  skin  was  of  a  dusky 
yellow  color;  the  tongue  was  dry,  brown,  and  furred;  respiration  44;  the 
pulse  100,  soft  and  compressible ;  the  abdomen  was  much  distended  with 
flatus,  and  fluctuation  could  also  be  felt ;  the  liver  extended  several  inches 
below  the  ribs,  and  there  was  tenderness  on  pressure  in  that  part.  In  the 
chest  there  were  general  bronchial  rales ;  he  was  delirious  at  night,  and  slept 
but  little  ;  the  motions  were  light  in  color,  the  bowels  relaxed,  the  urine  con- 
tained lithates  and  the  coloring  matter  of  bile.  Three  days  after  admission 
he  was  more  prostrate,  and  was  delirious ;  the  pulse  was  very  compressible ; 
lie  had  pain  in  the  right  hypogastric  region,  and  on  the  following  day  he 
died. 

On  inspection  severe  capillary  bronchitis  was  found  ;  the  larger  bronchi 
were  also  diseased ;  they  were  somewhat  congested,  and  contained  yellow- 
colored  tenacious  mucus.  The  heart  was  large,  and  had  around  it  a  consider- 
able quantity  of  fat  ;  the  right  ventricle  was  thin  ;  the  left  ventricle  had 
undergone  partial  fatty  degeneration.  The  valves  were  healthy,  with  the 
exception  of  slight  thickening  of  the  mitral.  Abdomen — There  were  several 
pints  of  yellow  serum  in  the  peritoneum ;  the  intestines  wrere  considerably 


DUODENUM.  255 

distended  with  flatus,  and  the  liver  extended  several  inches  below  the  ribs. 
The  duodenum  contained  bloody  mucus,  the  lining  membrane  was  very  much 
congested,  and  in  some  parts  ecchymosed.  The  lower  part  of  the  small  intes- 
tine contained  clayey  feces.  There  was  a  considerable  quantity  of  fat  in  the 
omentum,  and  in  the  abdominal  parietes. 

The  liver  weighed  7  Ibs.  ;  its  surface  was  smooth,  and  of  a  deep  greenish- 
yellow  color,  and  some  veins  were  seen  upon  it ;  the  acini  were  whitish  in 
color.  The  section  of  the  liver  appeared  coarse  along  the  smaller  branches 
of  the  vena  portse  ;  the  capillary  vessels  in  Glisson's  capsule  were  much  dis- 
tended, and  some  of  them  were  quite  turgid  with  blood.  The  smaller  biliary 
vessels  contained  tenacious  mucus,  and  their  lining  membrane  was  congested ; 
this  state  of  the  bile-ducts  contrasted  remarkably  with  the  pale  color  of  the 
veins.  The  cells  of  the  liver  were  gorged  with  fat,  some  of  them  were  dis- 
tended with  oil-globules ;  other  hepatic  cells  appeared  ruptured,  and  granules 
witli  oil-globules  were  dispersed  upon  the  field  of  the  microscope.  The  deep 
green  spots  did  not  present  any  cells,  but  only  granular  matter. 

The  larger  bile-ducts  were  free,  but  the  opening  into  the  duodenum  was 
very  much  congested ;  the  gall-bladder  was  empty  ;  the  kidneys  were  large 
and  congested ;  the  spleen  was  firm,  and  contained  several  n'brinous  masses. 

The  health  of  this  man  was  much  impaired  by  his  intemperate 
habits,  and  his  liver  had  probably  been  diseased  for  a  considerable 
period.  The  affection  of  the  chest  came  on  subsequent  to  his  admis- 
sion into  the  hospital,  and  consequently  after  the  jaundice.  There 
Avas  evidently  acute  disease  of  the  smaller  biliary  tubes,  as  indicated 
by  the  congestion  of  Glisson's  capsule,  by  the  congestion  of  the  lining 
membrane  of  the  biliary  tubes,  and  the  tenacious  mucus  they  con- 
tained ;  the  hepatic  structure  was  stained  with  bile.  The  bronchitis 
which  subsequently  took  place  was,  perhaps,  the  cause  of  the  fatal 
termination,  and  tended,  doubtless,  to  increase  the  congestion  of  the 
mucous  membrane.  The  very  congested  state  of  the  duodenum  near 
the  entrance  of  the  bile-ducts  indicated  an  extension  of  disease  from 
the  duodenum  to  the  bile-ducts,  or  vice  versa;  it  was  much  more  local- 
ized than  is  observed  in  the  secondary  congestion  of  the  mucous 
membrane  in  pulmonary  obstruction.  This  did  not  appear  to  be  an 
affection  in  which  much  benefit  could  be  obtained  from  the  admin- 
istration of  mercury,  but  rather  from  salines  with  sedatives. 
•  After  burns  the  mucous  membrane  of  the  duodenum  has  been 
found  greatly  congested,  and  in  several  cases  recorded  by  Mr.  Curling 
in  the  '  Medico- Chirurgical  Transactions'  this  part  of  the  intestine 
was  ulcerated.  This  statement  has  not  been  confirmed  by  the  obser- 
vations of  Dr.  Wilks,  recorded  in  the  'Guy's  Eeports'  for  1856.  I 
witnessed  many  of  the  cases  to  which  he  refers;  and  although  in 
some  the  first'part  of  the  duodenum  was  hyperaemic,  in  none  did 
I  observe  Liberation.  A  case  of  ulceration  of  the  duodenum  after  a 
burn  has  however,  been  placed  in  the  Museum  at  Guy's,  by  Sir  Wm. 
Gull.  The  child  survived  twenty-five  days,  but  died  comatose;  a 
small  cicatrizing  ulcer  was  found  in  the  first  part  of  the  duodenum. 

Since  the  former  edition  of  this  work  was  written  three  cases  of 
ulcer  of  the  duodenum  after  burns  have  occurred  at  Guy's. 

In  one  the  patient  was  admitted  for  an  extensive  scald,  and  died 
thirteen  days  after  admission.     The  duodenum  contained  two  small 


256  DUODENUM. 

ulcers,  one  the  size  of  a  pea,  the  other  of  a  hemp-seed,  and  Brunner's 
glands  were  swollen.  The  ulcers  appear  to  have  had  nothing  to  do 
with  the  man's  death. 

The  second,  a  male  child,  aet.  4,  died  nineteen  days  after  a  severe 
burn  of  the  lower  extremities.  He  was  doing  well,  and  the  burn 
was  healing,  when  three  days  before  death  he  began  to  pass  blood 
into  the  bed.  A  large  ulcer  was  found  in  the  duodenum,  and  the 
pancreatico-duodenal  artery  was  opened.  The  child  had  also  two 
small  ulcers  on  its  tongue,  extending  through  the  mucous  membrane. 

The  last  case  occurred  in  a  girl,  set.  13,  who  died  from  tetanus 
about  thirteen  days  after  an  extensive  burn.  The  stomach  was  ec- 
chymosed,  and  immediately  beyond  the  pylorus  was  a  small  ulcer 
with  thick  raised  edges.  The  thickening  was  considerable,  so  as  to 
cause  a  suspicion  that  the  ulcer  antedated  the  burn.  There  was 
irregular  injection  around  it. 

The  pathology  of  such  cases  is  still  involved  in  much  obscurity. 
Embolism  and  necrosis  of  tissue  from  blood  extravasation  after  con- 
gestion have  been  suggested,  as  we  have  already  mentioned,  in 
stating  the  hypothetical  explanations  of  acute  perforating  ulcer  of 
the  stomach. 

Mr.  Curling  describes  diarrhoea,  and  the  discharge  of  blood,  as 
having  arisen  from  this  condition  of  the  duodenum,  and  sometimes 
severe  haematemesis  and  prostration.  In  some  instances  death  took 
place  from  peritonitis  consequent  on  perforation.  After  such  severe 
injury  to  the  skin,  it  is  not  surprising  to  find  great  disturbance  of 
the  circulation  or  of  the  internal  organs,  and  especially  of  the  mucous 
membranes,  which  are  known  to  sympathize  so  closely  with  the 
skin  ;  in  some  of  these  cases  stimulants  appear  to  have  been  admin- 
istered freely,  and  these  have  probably  conduced  to  this  diseased 
appearance  of  the  duodenum. 

Chronic  congestion  produces  gray  discoloration  of  the  mucous  mem- 
brane ;  and  in  the  examination  of  the  discolored  part  we  find  that 
the  deep  color  is  produced  by  the  deposit  of  irregular  grains  of  pig- 
ment, very  thickly  placed  in  the  substance  of  the  mucous  membrane, 
near  to  its  upper  surface,  and  probably  in  the  coats  of  the  capillaries ; 
the  apparent  explanation  of  this  state  being,  that  gastro-enteritis,  or 
long-continued  hyperaemia,  has  been  followed  by  the  deposition  of 
haematine  or  pigment  in  the  substance  of  the  membrane. 

In  several  cases  of  this  gray  discoloration  the  appearance,  both  in 
children  and  in  adults,  has  been  uniform.  A  child,  set.  9,  a  thin, 
poorly  nourished,  pale  boy,  who  had  been  subject  for  some  time  to 
looseness  of  bowels,  whilst  running,  hurt  his  thigh ;  he  shortly  after- 
wards complained  of  pain  at  that  part ;  he  was  admitted  into  Guy's 
in  a  typhoid  state,  and  died  two  days  afterwards.  There  was  sup- 
puration in  the  brain,  and  gray  discoloration  of  the  mucous  mem- 
brane of  nearly  the  whole  of  the  small  and  large  intestines. 

Chronic  congestion  is  observed,  as  before  stated,  in  connection 
with  pulmonary  and  hepatic  congestion,  in  fact,  in  any  disease  which 
leads  to  distension  of  the  vena  portae  ;  and  we  also  find  a  less  general 
condition  of  congestion  of  the  first  part  of  the  duodenum  in  disease 


DUODENUM.  257 

of  the  pylorus,  whether  it  be  simple  fibroid  degeneration  and  hyper- 
trophy, or  true  cancerous  disease.  The  mucous  membrane  becomes 
thickened,  its  vessels  congested,  and  its  glands  enlarged  ;  sometimes, 
indeed,  so  much  so  that  the  glands  might  easily  be  mistaken  for 
minute  cancerous  tubercles.  The  continued  irritation  thus  leads  to 
hypertrophy  of  the  glands  of  the  mucous  membrane,  as  we  find  in 
other  similar  structures. 

The  duodenum  is  sometimes  found,  after  death,  to  be  filled  with 
blood,  and  a  coagulum  is  occasionally  moulded  into  its  exact  form. 
This  is  due  to  extravasation  of  blood  from  ulceration  and  perforation 
of  an  artery,  in  the  duodenum  or  in  the  stomach. 

As  to  the  symptoms  arising  from  the  conditions  just  described, 
they  appear  to  be  so  continually  bound  together  with  those  indica- 
tive of  simple  disease  of  the  contiguous  viscera,  that  definiteness  and 
certainty  cannot  be  attained.  The  vomiting  and  pain  connected 
with  hepatic  disease  and  gall-stone  are  possibly  due  partlv  to  the 
condition  of  the  duodenum.  In  the  latter  there  is  probably  spas- 
modic contraction  of  the  canal;  but  of  this  we  do  not  speak  with 
certainty.  In  the  cases  described  by  Mr.  Curling,  vomiting  was  a 
frequent  symptom  ;  and  the  bilious  evacuation  in  violent  vomiting 
indicates  that  the  first  and  second  portions  of  the  duodenum  have 
been  involved. 

Instances  are  not  unfrequently  met  with  in  which,  several  hours 
after  food,  there  is  pain  at  the  region  of  the  duodenum,  perhaps  with 
violent  vomiting,  faintness,  pallor  of  the  countenance ;  and  these 
symptoms  have  by  some  persons  been  referred  to  the  duodenum,  as 
a  form  of  duodenal  dyspepsia  or  inflammation;  by  others  to  the 
pyloric  valve ;  but  occasionally  jaundice  follows,  which  appears  to 
strengthen  the  former  supposition.  After  intemperance,  also,  vio- 
lent bilious  vomiting,  a  furred  state  of  the  tongue,  loss  of  appetite 
and  loathing  of  food,  diarrhoea,  tenderness  of  the  right  hypochon 
driac  region,  are  followed  by  jaundice;  and  we  are  prone  to  regard 
the  duodenum  as  being  in,  at  least,  a  state  of  great  hyperoamia. 
Exposure  to  cold,  with  great  mental  anxiety,  tends  also  to  promote 
this  state  of  duodenal  disease ;  and  the  mischief  appears  to  be  pro- 
pagated to  the  bile-ducts.  Sir  H.  Marsh  has  drawn  attention  to  the 
occurrence  of  jaundice  with  disease  of  the  duodenum,  in  the  'Dublin 
Medical  and  Surgical  Journal ;'  so  also  Dr.  Stokes,  in  the  '  Encyclo- 
paedia of  Practical  Medicine.' 

Congestion  of  the  duodenum  is  best  relieved  by  diminishing  portal 
and  hepatic  engorgement,  and  by  stimulating  the  abdominal  excre- 
tory organs  to  increased  action.  These  objects  may  be  attained  by 
giving  saline  and  mercurial  purgatives,  by  aperient  enemata.  and  by 
the  application  of  leeches  to  the  anus  or  to  the  scrobiculus  cordis. 
A  free  dose  of  calomel,  blue  pill,  or  gray  powder,  followed  by  a 
saline  aperient  draught,  often  acts  very  effectively  as  a  purgative  ; 
but  in  many  instances,  especially  where  the  morbid  condition 
arises  from  "chronic  pulmonary  disease  or  obstructive  disease  of 
the  heart,  small  doses  of  mercurials  may  be  very  advantageously 
combined  with  squills  and  foxglove,  so  as  thoroughly  to  act  on  the 
17 


258  DUODENUM. 

abdominal  excretory  glands ;  but  to  give  mercury  so  as  to  produce 
salivation,  or  to  prescribe  it  in  every  instance  where  bilious  fluid  is 
rejected,  appears  to  be  an  unwise  course.  The  most  bland  nourish- 
ment should  be  given,  and  abstinence  from  stimulants  should  be  en- 
joined; ice  and  cold  drinks  often  afford  great  relief  when  vomiting 
distresses  the  patient.  In  acute  hypersemic  states,  salines,  as  the 
solution  of  potash,  the  bicarbonates  of  potash  or  soda,  the  carbonates 
or  the  citrate  of  magnesia,  may  be  given  with  diuretics  in  efferves- 
cence or  otherwise,  as  the  individual  case  may  require.  But  in 
chronic  hypenemia,  where  there  is  profuse  secretion  of  mucus,  more 
advantage  will  be  found  from  the  dilute  nitric  or  nitro-hydrochloric 
acids,  with  laxatives,  as  taraxacum,  or  with  cinchona,  and  from  the 
old  compound  gentian  mixture  of  the  London  Pharmacopoeia. 

The  most  acute  form  of  inflammation  is  sometimes  observed  after 
the  administration  of  poisons.  In  a  case  of  poisoning  by  sulphuric 
acid,  where  several  square  inches  of  the  mucous  membrane  of  the 
stomach  had  been  destroyed,  the  duodenum  was  found  intensely  con- 
gested, and  covered  throughout  by  a  thin,  adherent,  diphtheritic 
membrane.  In  this  case  the  vomiting  and  dysphagia  disappeared  on 
the  third  day,  and  the  patient,  though  extremely  prostrate,  did  not 
appear  to  suffer  much  from  pain.  Arrowroot,  lirne- water,  and  milk, 
&c.,  were  administered,  and  for  a  week  it  was  thought  that  the 
patient  might  rally.  (See  "  Diseases  of  Stomach.")  In  ordinary 
practice,  however,  we  do  not  meet  with  this  form  of  disease. 

Ulceration  of  the  duodenum  varies  both  in  degree  and  extent ; 
sometimes  it  is  merely  superficial,  and  is  associated  with  other  dis- 
eases, as  in  a  patient  who  died  from  albuminuria  with  pericarditis, 
in  whom  the  duodenum  presented  superficial  ulceration,  the  result 
of  erythematous  or  acute  inflammation;  or  there  may  be  chronic 
ulcer,  resembling  that  found  in  the  stomach,  and  presenting  many 
symptoms  in  common  with  that  disease. 

Some  duodenal  ulcers  have  raised  and  thickened  edges,  with  de- 
pressed centres,  being  evidently  of  slow  formation.  They  are  mostly 
found  in  the  first  portion  of  the  duodenum;  and  since  this  part  of 
the  intestine  is  almost  surrounded  by  the  peritoneum,  we  sometimes 
have  fatal  peritonitis,  produced  by  perforation,  as  in  the  stomach, 
the  muscular  and  peritoneal  coats  being  also  destroyed  by  the  ulcer; 
or  adhesion  takes  place  with  the  adjoining  structures,  as  the  liver  and 
pancreas,  &c. ;  and  these  oftentimes  constitute  the  floor  of  the  ulcer. 

Several  cases  have  come  under  my  own  notice  the  early  symptoms 
of  which  were  exceedingly  slight,  till  sudden  and  fatal  peritonitis 
had  been  set  up  by  perforation.  In  some  instances  these  ulcers  have 
been  associated  with  violent  vomiting,  the  persistence  and  aggrava- 
tion of  which  were  attributed  to  this  diseased  condition ;  this  occurred 
in  a  young  woman,  aged  twenty-four,  who  was  admitted  into  Guy's 
Hospital  with  very  urgent  vomiting ;  the  pulse  was  small  and  fre- 
quent; she  was  pregnant,  and  died  in  a  short  time  from  peritonitis; 
a  small  ulcer  was  found  in  the  duodenum.1  The  vomiting  was  proba- 

1  Dr.  Hodgkin  on  'The  Pathology  of  Serous  and  Mucous  Membranes.' 


DUODEXUM.  259 

bly  referred  to  sympathetic  irritation  from  the  uterine  state ;  and  a 
favorable  prognosis  would  in  many  such  cases  have  been  given  till 
the  symptoms  of  peritonitis  came  on. 

The  second  portion  of  the  duodenum  is,  however,  also  liable  to 
ulceration,  as  in  a  case  preserved  in  the  museum  of  Guy!s,  where 
the  coats  of  the  whole  of  the  vertical  portion  on  the  pancreatic  side 
were  destroyed,  and  the  pancreas  formed  the  base  of  a  large  chronic 
ulcer,  in  the  centre  of  which  was  seen  the  opening  of  the  biliary  and 
pancreatic  duct.  There  was  a  small  ulcer  in  the  third  portion  of  the 
duodenum,  and  peritonitis  had  been  set  up ;  the  pancreas  was  en- 
larged. The  patient  was  forty-four  years  of  age,  and  had  empyema; 
he  became  exceedingly  emaciated  before  death,  and  suffered  from 
vomiting  as  well  as  from  meltena. 

Ulceration  is  sometimes  followed  by  constriction ;  and  adhesions 
also  frequently  form  between  the  first  part  of  the  duodenum  and  the 
gall-bladder ;  in  some,  ulceration  extends  from  the  gall-bladder  into 
the  duodenum,  thus  allowing  the  passage  of  calculi;  and  the  gall- 
bladder is,  in  other  cases,  entirely  obliterated. 

Pain  several  hours  after  food,  a  sallow  complexion,  furred  tongue, 
feebleness  of  circulation,  mental  depression,  nausea,  and  irritable 
bowels,  have  been  ascribed  to  ulceration  of  the  duodenum,  but  the 
facts  do  not  fully  warrant  this  conclusion.  In  the  several  instances 
we  have  observed  there  were  no  such  indications ;  in  some,  the  ulce- 
ration was  associated  with  disease  of  the  gall-bladder;  in  others, 
Avith  chronic  disease  of  the  liver ;  and  the  predisposing  and  exciting 
cause  of  the  hepatic  disturbance  had  probably  induced  the  duodenal 
mischief. 

Ulceration  of  the  duodenum  must  be  remembered  both  as  a  source 
of  fatal  perforation  and  of  intestinal  hemorrhage,  as  well  as  of  haema- 
temesis. 

The  treatment  of  these  cases  is  similar  in  all  respects  to  that  re- 
commended for  corresponding  gastric  disease. 

CASE  LXXXYI.  Ulceration  of  the  Duodenum.  Perforation — George 
E — ,  set.  30,  a  man  of  light  complexion,  and  of  steady  and  temperate  habits, 
was  admitted  into  Guy's  Hospital,  October,  1851.  He  was  by  trade  a  surgi- 
cal instrument  maker,  and  accustomed,  when  at  work,  to  exercise  pressure 
against  the  umbilicus.  Four  months  before  admission  he  had  slight  expecto- 
ration of  blood,  but  it  was  doubtful  whether  it  proceeded  from  the  lungs  or 
stomach.  On  October  20th,  whilst  apparently  in  good  health,  he  suddenly 
experienced  severe  pain  in  the  abdomen ;  to  use  his  expression,  he  was 
"  doubled  up  ;"  he  fell  down  in  a  fainting  state,  and  was  taken  into  a  drug- 
gist's shop,  where  ammonia  and  some,  castor  oil  were  administered.  The 
pain  was  situated  on  the  right  side.  On  admission,  he  was  in  a  state  of  col- 
lapse;  the  pain  of  which  he  complained  passed  in  the  course  of  the  ureter. 
On  the  following  morning  he  was  exceedingly  depressed,  the  skin  hot,  the 
abdomen  tender,  and  there  were  the.  symptoms  of  general  pertitonitis ;  vomit- 
ing of  coffee-ground  fluid  came  on,  and  pulsation  was  felt  at  the  scrobiculus 
cordis,  which  suggested  the  idea  of  aneurism.  He  survived  fifty-six  hours. 
On  examination,  the  peritoneum  was  found  to  be  intensely  inflamed ;  lymph 
was  effused,  and  castor  oil  was  found  floating  in  the  peritoneal  cavity.  At 
the  first  part  of  the  duodenum,  about  one  inch  from  the  pylorus,  an  ulcer  was 


200  DUODENUM. 

found  of  the  size  of  a  shilling ;  and  at  its  base  there  was  a  circular  opening, 
the  third  of  an  inch  in  diameter.  In  the  stomach  several  small  aphthoiis 
ulcers  were  observed,  and  two  small  ones  were  covered  with  coagula.  The 
remaining  parts  of  the  small  intestine  were  healthy  ;  so  also  the  cu-cum,  colon, 
kidneys,  spleen,  and  liver. 

In  the  chest  there  were  old  pleuritic  adhesions  on  both  sides,  especially  on 
the  left,  where  there  was  also  a  small  vomica,  with  indurated  lung,  and  thick- 
ened tubes. 

The  patient  was  only  thirty  years  of  age;  and,  as  he  believed,  in 
good  health,  though  evidently  of  feeble  constitutional  power,  as 
indicated  by  the  condition  of  the  lungs  and  the  previous  haemop- 
tysis ;  he  was  doubtless  phthisical,  but  the  disease  of  the  duodenum 
resembled,  in  its  insidious  character,  corresponding  disease  of  the 
stomach,  and  gave  no  previous  indication  of  its  existence. 

The  treatment  of  the  patient,  before  his  admission,  precluded  all 
chance  of  recovery ;  but  such,  unfortunately,  is  too  frequently  the 
case.  Brandy  and  castor  oil,  probably  both,  found  their  way  into 
the  peritoneal  sac:  and  the  necessary  removal  of  the  man,  at  first 
into  a  druggist's  shop,  then  to  his  own  home,  and  afterwards  a  con- 
siderable distance  to  the  hospital,  tended  to  induce  increased  extra- 
vasation and  peritonitis ;  the  judicious  administration  of  opium 
prolonged  life  many  hours. 

As  to  the  cause,  the  stooping  posture  at  his  work  probably  assisted 
to  produce  the  disease ;  but  this  is  involved  in  much  obscurity. 

The  position  of  the  pain  did  not  point  out  the  seat  of  the  perfora- 
tion ;  but  this  is  only  what  has  frequently  been  observed  in  cases  of 
gastric  ulcer ;  the  pain  was  principally  in  the  right  iliac  fossa,  and 
it  was  believed  that  the  ileurn,  or  appendix  caeci,  had  given  way. 

Mr.  Travers,  in  the  'Medico-Chirurgical  Transactions,'  mentions 
a  case  of  perforation  of  the  duodenum,  about  a  finger's  breadth  from 
the  pylorus,  in  a  gentleman,  aged  thirty-five,  who  was  strumous,  but 
considered  to  be  in  good  general  health.  There  was  a  large  irregular 
ulcer  in  the  first  part  of  the  duodenum,  with  a  small  perforation, 
which  had  led  to  fatal  peritonitis  and  death  in  thirteen  hours ;  the 
perforation  tooK  place  a  short  time  after  a  meal,  the  period  at  which 
such  accidents  are  generally  found  to  occur. 

CASE  LXXXVII Chronic  Ulcer  in  the  Duodenum.      Carcinoma  of  the 

Liver.  Jaundice.  Granular  Kidneys.  Obliteration  of  the  Bile  Di«-t — 
George  C — ,  oet.  46,  was  admitted  into  Guy's  Hospital  December  14,  !*.").'>, 
and  died  January  4.  For  a  fortnight  lie  had  had  jaundice,  vomiting,  and 
typhoid  symptoms,  and  for  three  months,  after  exposure  to  cold,  oedema  of  the 
lower  extremities  had  been  present.  In  the  liver  there  were  from  six  to  ten 
carcinomatous  tubercles  ;  the  bile  duct  was  obliterated  near  its  opening  into 
the  duodenum,  and  throughout  the  liver,  the  ducts  were  very  much  distended; 
the  cells  of  the  liver  were  normal.  In  the  first  portion  of  the  duodenum  there 
was  a  chronic  ulcer,  about  an  inch  in  diameter,  with  raised  thickened  edges, 
but  not  cancerous  in  its  character;  the  rest  of  the  intestine  was  healthy  ;  the 
kidneys  were  large,  and  their  sin-face  irregular  and  granular. 

The  disease  in  the  duodenum  was  not  discovered  till  after  death  ; 
the  cancerous  condition  of  the  liver,  inducing  pressure  on,  and  ob- 


DUODENUM.  261 

literation  of  the  ducts,  and  the  albuminuria  appeared  sufficient  to 
explain  all  the  symptoms.  The  ulcer  in  the  duodenum,  however, 
was  in  a  chronic  and  passive  condition,  but  nothing  was  ascertained 
as  to  its  cause ;  we  suppose  that  intemperance  increased  it.  We 
rarely  find  such  a  complication  of  disease  as  cancer  of  the  liver,  acute 
disease  of  the  kidney,  and  the  condition  of  the  duodenum  just  men- 
tioned. 

CASE  LXXXVIII. — Strum  on  s  Disease  of  the  Abdomen.  Perforating 
Ulcer  of  the  Duodenum  and  Caecum — Jane  B — ,  jet.  18,  was  admitted  into 
Guy's  Hospital  February  19,  1860,  and  died  October  4.  At  first  the  most 
prominent  symptom  was  vomiting,  which  was  supposed  to  be  hysterical ;  but 
after  a  time  the  abdomen  began  to  swell,  diarrhoea  came  on,  and  emaciation, 
&c.,  increased,  and  these  signs  indicated  the  presence  of  organic  disease. 
On  inspection,  the  body  was  much  emaciated ;  the  legs  were  cedematous. 
The  pleura  was  opaque,  from  the  recent  effusion  of  lymph,  and  the  lungs  were 
studded  with  tubercle.  The  peritoneum  was  acutely  inflamed  ;  the  intestines 
were  reddened,  and  there  was  lymph  upon  them ;  there  were  tubercular 
masses  upon  the  peritoneum,  covering  the  liver.  On  withdrawing  the  caecum, 
a  small  collection  of  offensive  pus  was  found  at  its  posterior  part,  and  the 
abscess  communicated  with  the  caecum  by  means  of  an  opening  about  an  inch 
above  the  ileo-colic  valve.  At  the  seat  of  perforation  was  a  transverse  ulcer, 
the  edges  of  which  were  injected ;  the  ulcer  was  one  inch  in  length,  and  the 
opening  one- third  of  an  inch.  A  few  other  ulcers  were  observed  in  the  colon, 
but  none  were  found  at  the  termination  of  the  ileum.  The  mesenteric  glands 
were  enormously  infiltrated  with  cheesy  deposit ;  so  also  were  the  lumbar 
glands.  Behind  the  first  portion  of  the  duodenum,  and  close  to  the  pancreas, 
was  a  collection  of  offensive  pus  in  front  of  the  spine.  This  abscess  com- 
municated with  the  first  portion  of  the  duodenum  by  an  opening  about  a 
quarter  of  an  incli  in  diameter;  the  ulceration  of  the  mucous  membrane  was 
more  extensive  than  the  external  opening ;  and  near  to  the  perforation  was  a 
second  smaller  ulcer  involving  the  mucous  membrane.  The  first  portion  of 
the  duodenum  appeared  to  be  contracted.  The  stomach  was  healthy  ;  so  also 
the  kidneys.  The  spleen  contained  a  softening  strumous  mass.  The  liver 
also  was  fatty. 

Although  the  history  of  this  case  is  imperfect,  I  have  introduced 
it  as  an  illustration  not  only  of  the  obscurity  of  strurnous  disease  in 
its  earlier  stage,  but  as  an  instance  of  irritation  of  the  duodenum  and 
colon,  followed  by  ulceration  and  perforation,  and  producing  perito- 
nitis, at  first  of  a  local,  but  afterwards  of  a  general  character.  The 
perforations  in  both  situations  were  not  directly  into  the  serous  cavity; 
the  abscess  connected  with  the  duodenum  was  close  to  the  pancreas 
upon  the  spine,  and  the  one  in  the  colon  was  placed  behind  the 
cascum. 

In  an  interesting  case  of  haematemesis  under  my  care  in  Ouy's 
Hospital  in  1875,  the  hemorrhage  which  proved  fatal  was  supposed 
to  have  come  from  the  stomach,  but  on  examination  after  death,  it 
was  found  that  a  large  ulcer  in  the  duodenum  had  perforated  the 
intestine,  and  led  into  a  sloughing  abscess  in  the  portal  fissure,  with 
which  the  vena  portse  communicated  by  an  ulcerated  opening  par- 


262  DUODENUM. 

tially  filled  by  clot;  the  common  bile-duct  and  hepatic  dnct  were  also 
divided ;  the  hepatic  artery  was  obliterated.1 

It  is  probable  that  this  perforation  of  the  duodenum  was  from 
without,  as  was  also  the  case  in  a  patient  under  my  care  in  lsi;ii. 
A  woman,  aged  46,  died  a  few  weeks  after  admission,  and  a  large 
abscess  was  found  on  the  right  side  of  the  abdomen  in  the  neighbor- 
hood of  the  ascending  colon,  along  which  it  extended  to  the  duode- 
num, where  it  opened  by  a  rounded  aperture  an  inch  beyond  the 
pylorus.  The  stomach  contained  a  little  altered  blood.  The  patient 
had  also  cancerous  disease  of  the  gall-bladder,  which,  however,  had 
no  apparent  connection  with  the  peritoneal  abscess. 

CASK  LXXXIX.  Gall-stone.  Ulceration  of  Gall-bladder  and  Duode- 
num. Large  Gall-stone  impacted  in  the  Jejunum.  Death  from  Hemorrhage. 
— A.  B — ,  jet.  56,  had  suffered  from  loss  of  appetite  and  mental  depression 
for  some  time,  due  to  family  anxiety  and  trouble.  lie  was  a  strong,  muscular 
man,  rather  stout,  and  he  had  generally  enjoyed  good  health.  On  November 
29th,  after  a  late  dinner,  severe  pain  came  on  in  the  region  of  the  stomach, 
and  for  several  hours  was  very  intense  ;  there  was  vomiting,  and  the  pain 
extended  to  the  back.  On  the  following  day  the  intense  pain  had  subsided, 
but  left  soreness  at  the  stomach,  at  the  scrobiculus  cordis,  and  in  the  region 
of  the  gall-bladder.  He  had  no  appetite,  and  the  tongue  was  furred  ;  a  pur- 
gative was  given  and  saline  medicine.  On  December  2d  he  had  become 
jaundiced  ;  the  pulse  was  good,  but  the  tongue  was  furred  ;  there  was  no 
appetite  for  food,  but  much  mental  depression.  The  symptoms  of  jaundice 
gradually  lessened.  On  December  loth  the  urine  was  still  deep  in  color, 
but  the  motions  were  less  pale.  He  lost  the  pain  at  the  stomach,  regained 
his  appetite,  the  urine  became  normal  in  color,  and  he  was  able  about  Christ- 
mas to  visit  his  friends  ;  the  skin,  however,  did  not  completely  regain  its 
color.  On  January  12th  he  returned  to  town,  feeling  tolerably  well,  but 
during  the  night  nausea  came  on.  On  Saturday,  13th,  sickness  supervened, 
and  he  took  blue  pill  with  colocynth  ;  the  bowels  acted  a  little.  On  14th  the 
vomiting-  persisted,  and  saline  effervescing  medicines  were  prescribed  ;  in  the 
evening  vomiting  of  blood  occurred  mixed  with  acid  fluid.  On  Monday, 
January  15th,  I  saw  him  in  consultation.  The  stomach  was  very  irritable; 
everything  was  at  once  rejected  ;  the  pulse  was  quiet,  80  ;  temperature  nor- 
mal;  the  abdomen  was  full,  but  there  was  no  tenderness;  he  complained  of 
soreness  across  the  abdomen,  just  above  the  umbilical  region,  and  hardness 
could  be  felt  at  the  scrobiculus  cordis,  which  was  thought  to  be  the  left  lobe 
of  the  liver;  there  was  no  fixed  pain,  and  no  evidence  of  hernia.  Bismuth 
medicine  in  effervescence  was  given,  and  a  dose  of  calomel  with  colocynth. 
On  the  16th  he  was  rather  easier,  but  there  was  no  action  from  the  bowels  ; 
the  pain  increased  in  the  afternoon  ;  the  calomel  and  colocynth  were  repeated, 
and  an  injection  used.  On  January  17th  there  was  still  no  action  of  the 
bowels  ;  a  dose  of  castor  oil  was  followed  by  violent  vomiting  of  brown  acid 
fluid  ;  no  flatus  was  passed  ;  the  pulse  was  80,  temp.  98°,  the  respiration 
easy  j  the  abdomen  was  lull  and  stipple,  and  tympanitic  ;  there  was  soreness 
in  the  epigastric  region;  no  peristalsis  could  be  seen.  It  seemed  evident 
that  there  was  obstruction  in  the  bowels  ;  purgatives  were  not  repeated,  but 
a  grain  of  opium  was  given,  and  a  turpentine  enema  was  used.  On  January 

18th The  opium  given  night  and  morning  had  relieved  the  sickness  ;  a  full 

injection  of  oil  and  afterwards  soap-and-water  produced  a  discharge  of  hard 

»  'See  'Path.  Trans.,'  vol.  xxvii,  1876. 


DUODENUM.  263 

scybala.  Still  there  was  no  free  action  from  the  bowels ;  the  pulse  was  80, 
temperature  still  normal,  the  abdomen  as  before  ;  the  urine  was  normal  in 
color,  tolerably  free  in  quantity,  sp.  gr.  1017,  and  it  contained  a  trace  of 
albumen.  On  the  19th  he  felt  better  in  the  morning,  but  as  he  could  not 
pass  urine  freely  a  hip-bath  was  allowed.  About  4  P.  M.  faintness  came  on, 
and  he  again  vomited  blood.  The  patient  became  restless.  Still  there  was 
no  action  from  the  bowels ;  no  flatus  was  passed,  but  the  urinary  bladder 
being  distended  a  catheter  was  introduced,  and  about  a  pint  of  urine  drawn 
off.  Ice  was  applied  externally,  and  some  was  swallowed,  and  astringents 
given.  Nutrient  injections  were  used  repeatedly.  At  10  P.M.  he  had 
rallied  ;  about  a  pint  of  blood  mixed  with  acid  fluid  had  been  rejected.  On 
January  20th,  about  5  A.  M.,  more  blood  with  clots  were  vomited,  but  he 
again  rallied.  On  the  21st  he  had  return  of  vomiting  several  times;  in  the 
evening  he  got  out  of  bed,  again  vomited  blood,  faintness  followed,  and  he 
died  about  8  P.  M. 

Post-mortem  examination  by  Dr.    Goodhart  twenty  hours  after  death 

Abdominal  wall  thickly  coated  with  fat.  On  opening  the  abdomen,  the 
omentum  and  liver  were  found  adherent  to  the  abdominal  wall  in  front  at  the 
upper  part.  The  jejunum  was  much  distended  and  dark  in  color  ;  on  tracing 
the  small  bowel  from  the  caecum  upwards,  the  ileum  was  small  and  paler  till 
its  upper  part  was  reached.  Here  it  was  blocked  by  a  gall-stone  of  black 
color,  somewhat  irregular  in  shape,  with  a  facet  at  either  end  of  its  long 
diameter,  and  measuring  about  l^Xl^  inches.  It  moved  about  in  the  bowel 
under  external  manipulation  with  considerable  freedom,  though  it  would  not 
pass  far,  and  it  quite  filled  the  canal.  Below,  the  bowel  was  empty  or  nearly 
so,  and  above,  it  was  considerable  dilated,  and  contained  clayey  and  brownish 
pultaceous  fecal  matter.  The  mucous  membrane  where  the  stone  lodged  was 
superficially  ulcerated  in  some  parts.  About  three  inches  higher  up  was  a 
smaller  gall-stone  more  like  a  fragment  than  a  distinct  calculus.  It  lay  loose 
in  the  intestine  with  some  fluid,  brownish  fecal  matter,  and  was  easily  crushed 
between  the  fingers.  Nothing  else  abnormal  was  found  till  the  duodenum 
was  reached.  On  reaching  the  right  lobe  of  the  liver  the  first  part  of  the 
duodenum  was  seen  to  be  pulled  upwards  and  adherent  to  the  fissure  for  the 
gall-bladder,  and  to  hide  the  gall-bladder  from  view.  The  latter  was  further 
concealed  by  the  omentum,  also  adherent  to  the  liver.  To  the  right  of  these 
structures  was  a  little  treacly  blood,  about  a  drachm,  lying  close  to  the  duo- 
denum underneath  the  liver,  but  free  in  the  peritoneum.  Its  position  there, 
must  have  been  of  recent  occurrence,  as  it  was  not  shut  in  by  adhesions,  and 
yet  no  peritonitis,  was  present.  Dissecting  out  the  gall-bladder  and  the  ves- 
sels of  the  portal  fissure,  it  was  found  that  the  fundus  of  the  gall-bladder,  the 
cavity  of  which  was  much  contracted,  opened  by  a  large  hole  into  a  shreddy 
cavity  which  contained  blood  of  treacly  consistency;  this  cavity  also  opened 
by  a  large  and  irregular  aperture  into  the  duodenum,  immediately  beyond  the 
pylorus  at  its  anterior  part.  The  vessels  of  the  portal  fissure  ran  to  the  left 
and  in  front  of  the  cavity  external  to  the  gall  bladder,  and  they  were  not  im- 
plicated, with  the  exception  of  the  main  branch  of  the  hepatic  duct  to  the 
right  lobe  of  the  liver.  This  was  quite  destroyed,  and  the  truncated  ex- 
tremity opened  into  the  abscess  immediately  behind  its  junction  with  the  duct 
from  the  other  side  to  form  the  main  hepatic  duct ;  the  cystic  duct  was  also 
destroyed.  All  the  other  vessels  were  normal.  The  cystic  artery  of  the 
pancreatico-duodenal,  splenic  and  gastric  arteries,  were  all  quite  sound,  and 
so  also  were  all  the  branches  of  the  portal  vein  in  the  neighborhood.  The 
source  of  the  hemorrhage  could,  therefore,  only  be  attributed  to  venous  oozing 
from  the  surface  of  the  ulcer  in  the  gall-bladder  and  the  duodenum,  and  the 


264  DUODENUM. 

sloughing  cavity  outside.  The  liver  substance  was  unaffected  by  the  ulcera- 
tive  action,  which  was  quite  external  to  the  capsule  of  the  organ.  The  liver 
was  small,  but  quite  healthy,  except  a  slight  excess  of  fat.  The  kidneys 
were  rather  large  and  coarse ;  the  right  contained  a  cyst ;  the  spleen  was 
pale  but  healthy.  The  lungs  were  emphysematous.  The  muscular  fibre  of 
the  heart  was  tatty. 

From  the  observations  I  bad  made  in  November  I  felt  convinced 
that  the  patient  had  gall-stone,  and  I  supposed  it  had  passed,  although 
one  was  not  detected.  In  the  last  attack  the  hemorrhage  was  differ- 
ent from  that  which  we  generally  observe  in  gastric  ulcer ;  the  blood 
was  poured  out  more  gradually.  The  clinical  history  was  not  that 
of  gastric  ulcer,  neither  was  the  hemorrhage  such  as  we  have  in 
engorgements  of  the  portal  circulation.  From  its  gradual  character,  I 
thought  it  probable  that  it  arose  from  the  duodenum  and  was  venous 
in  character.  It  was  evident,  also,  that  there  was  mechanical  ob- 
struction of  the  intestine,  for  purgatives  were  instantly  rejected,  no 
true  action  from  the  bowels  took  place,  and  no  flatus  was  passed.  It 
occurred  to  me  that  possibly  a  gall-stone,  impacted  high  up  in  the 
small  intestine,  was  the  cause  of  the  obstruction,  and  this  opinion 
was  confirmed  by  the  post-mortem  examination,  and  also  that  the 
hemorrhage  arose  from  an  ulcer  in  the  duodenum. 

No  peristaltic  movement,  although  several  times  looked  for,  could 
be  detected,  and  yet  the  gall-stone  was  pushed  down  to  the  end  of 
the  jejunum.  It  is  true  that  the  abdomen  was  covered  by  a  thick 
stratum  of  fat,  which  would  render  the  observation  of  movement 
more  difficult ;  again,  the  intestine  was  filled  with  blood,  and  it  is 
possible  that  the  peristaltic  movements  were  very  feeble  on  account 
of  the  hemorrhage.  Another  circumstance  of  great  interest  was  the 
comparative  absence  of  pain,  although  an  enormous  gall-stone,  more 
than  an  inch  in  diameter,  had  ulcerated  its  way  through  the  gull- 
bladder,  then  outside  the  bile  duct,  into  the  duodenum ;  there  was 
soreness,  but  no  severe  pain  and  no  rigor.  This  comparative  absence 
of  pain  I  have  previously  noticed  in  a  case  where  a  large  gall-stone 
had  led  to  fatal  obstruction  by  impaction  immediately  beyond  the 
duodenum.  »  ^ 

The  following  is  a  table  of  the  cases  in  which  we  have  found  ulce- 
ration  of  the  duodenum. 


DUODENUM. 


265 


Sex. 

Age. 

Disease  or  injury. 

Cause  of  death. 

Remarks. 

F. 

13 

Burn 

Tetanus 

Thirteen    days     after  ; 

stomach. 

M. 

4 

Burn 

Hemorrhage 

Ecchymosed    ulcer    on 

the  tongue. 

M. 
F. 

30 

Scald 
Primary  disease 

Exhaustion 
Portal  pyaemia 

Braune  glands  swollen. 

M. 

39 

Amyloid  viscera 

Scrofulous  pyelitis 

M. 

... 

Diseased  knee 

Hemorrhage 

M. 

55 

Hydrocephalus 

Convulsions 

Hypertrophy  and  dila- 

tation ;  stomach. 

F. 

55 

Renal  disease 

Large  white  kidney 

F. 

12 

Disease  of  hip 

Hemorrhage  from  ulcer 

M. 

30 

Primary  disease 

Perforation,  peritonitis 

M. 

46 

Cancer  of  liver,  &c. 

Exhaustion  from  cancer,  &c. 

F. 

18 

Tapes  mesenterica 

... 

Abscess  behind  caecum, 

&c. 

M. 

56 

Gall-stone 

Hemorrhage  ;  gall-stone  im- 

Ulcer due  to  the  pas- 

pacted. 

sage  of  a  gall-stone. 

Cancerous  disease  of  the  duodenum. — It  is  far  more  frequent  to  find 
the  duodenum  secondarily  involved,  than  to  be  itself  the  primary 
seat  of  this  fatal  form  of  disease.  In  many  cases  the  disease  appears 
to  have  commenced  in  the  pancreas  or  in  the  adjoining  lymphatic 
glands,  or  in  the  liver;  and  although  cancer  of  the  stomach  and  of 
the  pylorus  is  generally  very  defined  and  ceases  abruptly  at  the  com- 
mencement of  the  duodenum,  such  is  not  constantly  the  case ;  for 
the  disease  sometimes  extends  onward  into  the  pyloric  portion  of 
the  duodenum.  Again,  it  is  oftentimes  very  difficult  to  state  pre- 
cisely in  which  part  the  disease  has  commenced. 

As  to  the  symptoms,  the  earlier  ones  are  often  very  insidious ;  and 
are  more  likely  to  be  mistaken  for  hepatic  disease  than  the  early 
symptoms  of  cancer  of  the  stomach :  still  the  first  indications  are 
those  of  dyspepsia  and  malaise,  sallowness  of  complexion,  mental 
depression,  followed  by  nausea,  vomiting,  and  sometimes  pain,  seve- 
ral hours  after  food  has  been  taken.  The  patient  emaciates,  and  a 
hardness  or  tumor  is  felt  about  the  cartilage  of  the  tenth  rib ;  a  very 
difficult  question  then  arises,  as  to  whether  it  is  the  pylorus  that  is 
affected,  or  the  pancreas,  or  the  lymphatic  glands.  Pulsation  com- 
municated to  the  growth  may  suggest  the  idea  of  aneurism.  In 
aneurismal  disease  the  vomiting  is  a  less  marked  symptom,  and  the 
pulsation  more  uniform;  the  pain  also  is  often  very  intense.  In 
primary  pancreatic  disease  the  tumor  is  generally  more  central ;  the 
evacuations  have  been  found  sometimes  to  contain  fat,1  and  until 
pressure  take  place  on  the  duodenum,  or  the  disease  extend  to  the 
stomach,  and  to  the  lymphatic  glands,  the  symptoms  are  less  pro- 
nounced. Pyloric  disease  is  indicated  by  more  persistent  vomiting 
than  we  find' in  simple  duodenal  disease.  Occasionally  local  ulcera- 
tion,  with  chronic  thickening,  takes  place  at  the  union  of  the  trans- 


1  The  observations  of  Bernard  tend  to  show  that  this  symptom  would  be  a  constant 
one,  if  the  duct  were  always  obstructed. 


266  DUODENUM. 

verse  and  ascending  colon,  or  cancerous  disease  may  be  developed 
at  this  site,  arid  subsequently  perforate  the  duodenum.  (See  "Cancer 
of  the  Colon.")  The  formation  of  adhesions  with  the  duodenum  in 
these  latter  instances  sometimes  causes  partial  mechanical  obstruc- 
tion ;  vomiting  is  produced,  and  thus  the  diagnosis  is  rendered  unu- 
sually difficult ;  such  was  the  case  in  an  instance  which  we  shall 
presently  give.  In  all  these  maladies  there  is  emaciation,  pallor, 
cachexia.  Lastly,  we  must  refer  to  numerous  diseases  of  the  ornen- 
tum  and  of  the  liver  as  complicating  the  diagnosis.  Here,  however, 
the  difficulty  is  less ;  for  in  the  former  the  tumor  is  more  central, 
there  is  greater  mobility,  and  the  gastric  symptoms  are  less  marked  ; 
in  the  latter,  hepatic  cancer,  the  tumor  is  more  strictly  in  the  hypo- 
chondrium,  and  the  enlarged  gland  may  be  often  felt  with  tubera 
projecting  from  its  surface. 

The  termination  of  cancer  in  the  duodenum  is  generally  one  of 
progressive  emaciation  and  cachexia.  If  enlarged  glands  press  upon 
the  bile-ducts,  jaundice  will  be  added  to  the  symptoms ;  if  perforation 
or  sloughing  takes  place,  local  abscess  occasionally  forms,  which,  by 
giving  resonance  on  percussion,  adds  increased  difficulty  in  forming 
a  correct  diagnosis. 

The  treatment  of  these  cases  generally  consists  in  trying  to  relieve 
the  distress  and  pain  of  the  patient,  and  in  sustaining  his  exhausted 
powers.  Anodynes  are  required — opium,  morphia,  chloroform,  or 
its  preparations ;  and  bland,  but  very  nutrient  diet,  and  especially 
of  a  fluid  kind,  should  be  given.  Stimulants  assist  in  keeping  alive 
the  flickering  flame  of  life.  When  great  sallowness  of  the  com- 
plexion comes  on,  or  jaundice,  it  is  very  unwise  to  give  mercurials ; 
they  hasten  degenerative  changes,  exhaust  the  patient,  without  any 
mitigation  of  his  sufferings,  and  tend  to  hasten  the  fatal  termination. 

CASE  XC.      Cancer  of  the  Duodenum (Reported  by  Mr.  C.  Longmore.) 

— James  R — ,  set.  40,  was  admitted  under  my  care  into  Guy's  Hospital  June 
23d,  1858,  and  died  July  oth.  He  was  by  trade  a  coach-builder,  and  he  had 
resided  at  Newington;  his  habits  of  life  had  been  temperate,  and  with  the 
exception  of  a  slight  winter  cough,  he  had  enjoyed  good  health  till  Christmas 
of  the  preceding  year.  The  first  symptom  of  which  he  complained  was  a 
shooting  pain  in  the  back  and  stomach  ;  the  pain  at  last  became  very  violent, 
especially  at  night  after  he  had  finished  his  work  ;  there  were  also  moving 
pains  in  both  sides,  especially  on  the  right,  and  in  the  testicles  ;  he  had  neither 
cough  nor  vomiting ;  about  four  weeks  prior  to  his  admission  swelling  of  the 
feet  came  on,  and  after  a  few  days  his  abdomen  began  to  swell.  He  was  a 
man  of  sallow  complexion,  with  dark  hair  and  eyes  ;  he  was  much  emaciated, 
but  the  feet  and  legs  were  anasarcous  ;  there  was  dulness  on  percussion  at  the 
sides  of  the  abdomen,  and  fluctuation  was  indistinctly  felt.  In  the  scrotum 
on  the  right  side  was  a  large  hernial  protrusion  ;  and  in  the  abdominal  cavity 
a  hard  tumor  could  be  felt,  situated  on  the  level  of  the  umbilicus,  and  two 
inches  to  its  left  side  ;  the  tumor  was  an  inch  -and  a  half  to  two  inches  in 
diameter,  dull  on  percussion,  but  there  was  resonance  around  it ;  on  pressure 
very  slight  pain  was  produced.  Over  the  cartilage  of  the  tenth  rib  then;  was 
also  a  minute  pea-like  tumor.  The  thoracic  viscera  were  apparently  healthy  ; 
the  pulse  feeble,  compressible,  70.  The  surface  of  the  body  was  cool.  The 
tongue  was  coated  with  a  brown  fur  in  the  centre,  but  was  red  at  the  tip. 


DUODENUM.  267 

The  bowels  were  freely  acted  upon, 'and  the  evacuations  were  paler  than 
natural.  The  urine  was  scanty,  sp.  gr.  1032,  free  from  albumen,  but  loaded 
with  lithates.  Small  doses  of  acetate  of  morphia  were  given,  and  dilute 
nitric  acid  with  infusion  of  cusparia.  On  June  25th,  the  abdomen  had  greatly 
increased  in  size,  it  was  very  tense  and  resonant  on  percussion  except  in  the 
lumbar  regions.  On  the  26th,  the  report  states  that,  during  the  previous 
evening  and  on  this  day,  he  vomited  about  two  quarts  of  bitter  bilious  fluid, 
but  became  more  comfortable  after  its  rejection  ;  although  a  sensation  of  in- 
tense thirst  came  on.  On  the  28th  he  had  become  jaundiced,  and  complained 
of  jrreat  pain  across  the  loins,  of  an  aching,  dragging  character. 

On  the  evening  of  the  3d  July  vomiting  of  coffee-ground  substance  came 
on,  and  continued  till  his  death  on  the  5th,  at  11  P.  M.  The  tumor  several 
days  previously  seemed  larger  and  more  distinct.  Inspection  was  made  six- 
teen hours  after  death.  There  was  rigor  mortis  ;  the  whole  body  was  jaun- 
diced ;  the  tissue  of  the  heart  was  pale  and  softened.  The  liver  was  much 
enlarged.  A  tumor  about  the  size  of  the  fist  surrounded  the  vessels  at  the 
fissure  of  the  liver;  the  duodenum  was  situated  in  front  of  this  growth,  and 
was  adherent  to  it.  The  commencement  of  the  duodenum  was  quite  de- 
stroyed by  cancerous  ulceration,  and  a  large  slough  occupied  the  position  of 
the  first  portion.  The  interior  of  the  intestine  communicated  with  the  can- 
cerous mass  beneath  it ;  the  cancer  tumor  was  altered  in  structure,  and  con- 
tained blood.  The  gall-bladder  was  distended  to  about  twice  its  natural  size, 
and  contained  a  few  gall-stones.  The  hepatic  duct  was  slightly  obstructed. 
The  vena  cava  was  in  several  places  penetrated  by  the  cancerous  growth. 
The  whole  liver  was  filled  with  cancerous  tubera,  which  were  rounded, 
vascular,  and  softened.  The  disease  appeared  to  run  more  especially  in  the 
course  of  the  portal  vessels,  as  if  its  entry  into  the  liver  had  been  by  Glis- 
son's  capsule.  The  cancer  growth  consisted  of  large  nucleated  cells.  The 
pancreas,  supra-renal  capsules,  and  kidneys,  were  healthy. 

Instances  of  this  kind  are  often  very  difficult  of  diagnosis,  as  to 
the  precise  seat  of  the  disease;  the  glands  close  to  the  duodenum 
were  probably  first  affected;  but,  although  really  behind  the  duode- 
num, the  intestine  did  not  cause  resonance,  probably  on  account  of 
its  becoming  early  implicated  in  the  disease.  -The  subsequent  symp- 
toms arose  from  pressure  on  the  bile-ducts  and  the  vena  portre,  and 
from  the  degeneration  of  the  cancerous  growth.  Mr.  John  Dix,  of 
Hull,  has  recorded  a  very  interesting  case  somewhat  allied  to  this; 
and  in  which  there  was  a  tumor  apparently  connected  with  the  liver, 
but  resonant  on  percussion.  "The  tumor  was  hepatic  and  malignant. 
It  was  softening  down — sloughing,  in  fact ;  and  in  this  process  it 
had  involved  and  laid  open  the  duodenum,  to  which  it  was  attached ; 
and  whence  air  had  escaped  into  a  circumscribed  cavity  formed  by 
the  tumor  behind,  and  the  abdominal  wall  in  front,  to  both  of  which 
the  transverse  colon  was  adherent  below,  forming  the  lower  boundary" 
of  the  resonant  space.  The  patient,  "  Mrs.  M— ,  aged  fifty-five,  was 
pallid,  feeble,  and  emaciated;  she  complained  chiefly  of  pain  in  the 
right  side  of  the  abdomen,,  with  vomiting  and  other  symptoms  refer- 
able to  derangement  of  the  hepatic  and  digestive  functions.  She  had 
suffered/before  that  time,  from  jaundice  and  gall-stones."  She  died 
in  about  three  months  after  the  first  medical  examination^;  but  the 
resonance  in  front  of  the  tumor  remained  till  death. 

Primary  cancer  of  the  duodenum  is  of  rare  occurrence ;  a  patient, 


268  DUODENUM. 

under  my  care  in  Guy's  in  1872,  aged  forty-five,  suffered  eighteen 
months  before  admission  from  violent  vomiting  and  purging ;  for  a 
week  he  was  jaundiced,  and  he  gradually  sank;  the  stomach  and 
pylorus  were  healthy,  but  the  first  portion  of  the  duodenum  was 
occupied  by  a  large  cancerous  growth  as  large  as  a  cricket  ball,  soft, 
milky,  vascular,  and  invading  the  liver  by  direct  extension. 

Instances  also  occur  of  primary  disease  of  the  pancreas  extending 
to  the  duodenum,  and  we  have  witnessed  such  cases  in  which  the 
mucous  membrane  of  the  duodenum  had  become  infiltrated  with 
medullary  cancer.  Cancerous  cachexia  is  then  generally  well  marked, 
but  till  the  pylorus  or  duodenum  become  involved,  vomiting  is  not 
generally  a  prominent  symptom.  We  have  also  seen  the  duodenum 
perforated  in  cancerous  disease  of  the  caecum,  which  had  extended 
upwards;  and  in  another  case,  one  of  villous  cancer  of  the  bile-ducts, 
a  large  cyst  had  formed  in  the  right  side  of  the  abdomen  below  the 
liver  and  opened  into  the  upper  third  of  the  duodenum  by  four 
separate  ulcers. 

Mechanical  obstruction. — Other  parts  of  the  intestine  are  much 
more  liable  to  obstruction  of  a  mechanical  character  than  the  duode- 
num. In  the  course  of  several  years  we  have  observed,  or  have 
found  recorded,  isolated  cases  of  this  kind  of  obstruction,  arising 
from  the  following  causes : — 

1.  Peritoneal  adhesions. 

2.  Gall-stones  of  large  size,  which  having  ulcerated  through  the 
coats  of  the  gall-bladder,  have  become  impacted  in  the  duodenum, 
and  have  led  to  fatal  obstruction. 

3.  Enlarged  glands,  infiltrated  by  cancer,  compressing  the  second 
or  third  part  of  the  duodenum. 

4.  Diseased  pancreas. 

5.  Hydatid  disease  of  the  liver,  opening  into  the  duodenum. 

6.  Foreign  bodies. 

It  is  exceedingly  common  to  find,  after  death,  that  adhesions  have 
taken  place  between  the  first  portion  of  the  duodenum  and  adjoining 
viscera,  either  the  inferior  surface  of  the  liver  and  gall-bladder,  or 
the  transverse  colon  ;  and,  in  many  instances,  the  impediment  to  the 
free  passage  of  the  chyme  is  so  slight  that  no  symptoms  point  to  any 
disturbed  function.  In  the  following  case  adhesions  with  the  colon 
were  followed,  however,  by  great  distension  of  the  first  part  of  the 
duodenum  ;  but  there  was  also  some  ulceration  of  the  same  part  of 
the  intestine ;  there  was  chronic  ulcer  of  the  colon,  and  chronic  as 
well  as  acute  peritonitis,  with  strumous  and  glandular  disease,  so 
that  there  was  considerable  difficulty  in  unravelling  the  symptoms, 
which  resembled  those  of  organic  disease  of  the  stomach.  Still  we 
believe  that  the  pain  and  the  vomiting  several  hours  after  food  had 
been  taken,  were  the  result  of  this  duodenal  obstruction. 

CASE  XCI — -Chronic  Peritonitis.  Acute  Peritonitis.  Tubercular  De- 
posit on  the  Serous  Membranes  and  in  the  Glands.  Constriction  of  the 
Duodenum,  and  great  Dilatation  of  its  first  portion.  Small  Ulcer  in  the 
Duodenum.  Large  Chronic  Ulcer  in  the  Colon — William  C — ,  a^t.  38,  was 
admitted  into  Guy's  Hospital  under  my  care,  April  15,  1861.  He  was  a 


DUODENUM.  269 

married  man,  by  trade  a  cooper,  and  he  had  resided  at  Dockhead.  About 
seven  years  previously  he  suffered  from  severe  pain  at  the  epigastric  region  ; 
and  tor  several  years  since  that  time  he  had  had  pain  at  the  same  part, 
but  less  acute  in  its  character.  He  had  never  had  any  hemorrhage  from 
the  stomach,  but  he  had  complained  of  slight  pain  in  the  dorsal  region,  be- 
tween the  sixth  and  eighth  vertebrae.  Some  years  before  he  had  had  violent 
vomiting ;  but  since  that  time  vomiting  had  been  slight,  the  attacks  coming 
on  some  time  after  food  had  been  taken.  He  had  had  slight  pyrosis,  and 
acid  taste  after  vomiting.  The  pain  at  the  epigastric  region  was  not  constant, 
but  it  was  worse  after  lood,  and  was  especially  aggravated  by  constipation. 

On  admission  he  was  very  much  emaciated,  witli  a  sallow  complexion,  and 
on  the  forehead  there  was  a  bronzed  condition  of  his  skin  ;  the  skin  at  the 
elbows  was  also  slightly  discolored.  There  was  moderate  tenderness  at  the 
scrobiculus  cordis  ;  the  abdomen  was  rounded  and  supple ;  no  tumor  could 
be  felt ;  the  bowels  were  rather  confined  ;  the  pulse  was  very  compressible  ; 
the  tongue  was  red  in  patches.  No  disease  could  be  detected  in  the  lungs  or 
heart.  The  patient  stated  that  the  bronzed  color  of  the  forehead  had  existed 
for  three  years,  and  had  been  produced  by  exposure  to  the  sun  ;  the  lower 
part  of  the  abdomen  was  also  found  to  be  slightly  discolored. 

On  April  20,  the  bowels  were  freely  moved,  and  he  had  severe  pain  at  the 
scrobiculus  cordis  ;  the  pain  was  neither  relieved  nor  modified  by  any  change 
of  position. 

He  continued  in  the  same  prostrate  condition  without  pain  or  vomiting 
till  June  11,  when  violent  pain  and  symptoms  of  acute  peritonitis  came  on, 
and  he  sank  on  the  13th. 

1 4th.  Inspection. — The  body  was  very  much  emaciated.  Chest. — On  the 
left  side  the  pleura  was  firmly  adherent,  and  on  tearing  it  away,  rounded, 
yellowish  tubercles,  two  to  three  lines  in  diameter,  were  found  thickly  cover- 
ing the  costal  surface.  The  left  lung  itself  was  very  small ;  but  there  were 
no  tubercles  in  it.  The  right  pleura  was  free  from  adhesions  or  tubercles, 
and  the  lung  was  also  quite  healthy.  The  heart  and  pericardium  were 
normal.  There  were  several  yellowish-white  tubercular  masses  in  the  glands 
in  the  anterior  mediastinum.  On  opening  the  abdomen,  the  intestines  were 
seen  to  be  distended  ;  and  the  enlarged  transverse  colon,  extending  from  one 
hypochondriac  region  to  the  other,  prevented  the  stomach  from  being  seen. 
There  were  numerous  peritoneal  adhesions,  especially  at  the  upper  part  of  the 
abdomen,  the  transverse  colon,  stomach,  and  duodenum,  being  united  firmly 
to  the  under  sur'ace  of  the  liver.  The  coils  of  the  small  intestines  presented 
considerable  injection  at  their  lines  of  contact ;  but  neither  was  lymph  effused, 
nor  had  the  serous  membrane  lost  its  shining  color.  Numerous  tubercles 
were  present  on  the  serous  membrane  ;  some  were  exceedingly  small,  others 
three  or  four  lines  in  diameter,  and  they  were  situated  on  the  intestines  or  on 
the  peritoneal  surface  of  the  liver.  The  mesenteric  glands  were  extensively 
diseased ;  and  all  the  glands  situated  in  the  neighborhood  of  the  pancreas, 
and  near  the  origin  of  the  thoracic  duct,  were  enlarged,  although  it  could  not 
be  demonstrated  that  the  duct  was  compressed.  The  glands  contained  much 
cheesy  and  cretaceous  matter,  and  some  more  recent  semi-transparent  deposit. 
On  removing  the  transverse  colon,  the  stomach  was  found  to  be  distended, 
and  an  elongated  sac  was  produced,  partially  contracted,  about  three  inches 
from  the  right  extremity;  this  sac  was  at  first  supposed  to  be  from  hour- 
glass contraction  of  the  stomach,  but,  on  opening  it,  the  first  contraction  was 
seen  to  be  pylorus,  and  the  second  enlargement  was  an  enormously  distended 
first  part  of  the  duodenum.  The  stomach  and  duodenum  contained  grayish- 
green  tiuid  and  mucus.  The  mucous  membrane  of  the  stomach  did  not  pre 


270  DUODENUM. 

sent  any  abrasion,  thickening,  nor  ulceration,  nor  was  the  pylorus  hypertro- 
phied  ;  there  was  a  little  arborescent  injection.  The  sac  formed  by  the  first 
part  of  the  duodenum  was  capable  of  holding  eight  to  ten  ounces  of  fluid,  and 
was  also  injected.  Immediately  beyond  the  pylorus  was  a  small  ulcer  about 
five  lines  by  three  in  size,  its  edges  rounded  and  without  any  injection  ;  it 
did  not  extend  into  the  muscular  coat.  Three  inches  from  the  pylorus  the 
intestine  was  narrowed,  and  there  was  a  constriction  resembling  a  second 
pylorus;  there  was  no  thickening  nor  cicatrix,  and  it  appeared  probable  that 
the  peritoneal  adhesions  had  looped  up  the  intestine.  On  the  gastric  side  of 
this  constriction  there  was  a  small  pouch,  capable  of  admitting  the  tip  of  the 
finger.  The  rest  of  the  duodenum,  the  jejunum,  and  the  ileum.  were  healthy, 
with  the  exception  of  one  or  two  small  ulcers  with  tubercular  deposit  on  their 
peritoneal  surface.  Peyer's  glands  were  healthy.  The  caeeum  and  appendix 
also  were  normal.  In  the  ascending  colon  the  solitary  glands  were  verv  dis- 
tinct, and  at  the  commencement  of  the  transverse  colon  were  the  remains  of 
an  old  ulcer ;  for  two  to  three  inches  the  mucous  membrane  was  irregularly 
destroyed  and  puckered,  and  of  a  gray  color.  Tiie  rest  of  the  intestine  was 
normal.  The  supra- renal  capsules,  the  kidneys,  and  the  liver,  were  healthy; 
two  or  three  strumous  tubercles  were,  however,  situated  on  the  peritoneal 
surface  of  the  liver. 

In  mechanical  duodenal  obstruction  from  the  second  cause,  impac- 
tiou  of  a  gall-stone,  the  symptoms  resemble  those  produced  by  inter- 
nal strangulation  of  the  intestine,  or  by  hernia,  but  vomiting  is  set 
up  at  a  very  early  period,  and  is  of  a  severe  character.  The  vomited 
matters,  however,  cannot  have  a  stercoraceous  odor  nor  appearance. 
The  diagnosis  is  generally  obscure  and  difficult ;  but  where  the  symp- 
toms of  the  passage  of  a  gall-stone,  namely,  intense  pain  in  the  hypo- 
ehondrium,  vomiting,  and  subsequent  jaundice,  are  followed  also  by 
the  symptoms  of  insuperable  obstruction,  the  nature  of  the  malady 
is  sufficiently  clear;  but  in  the  ulceration  of  a  large  gall-stone  through 
the  coats  of  the  gall-bladder  into  the  duodenum,  the  indications  of 
disease  may  be  so  slight  as  to  be  almost  overlooked,  and  the  subse- 
quent obstruction  cannot  then  be  distinguished  from  strangulation 
taking  place  high  up  in  the  intestine.  The  impaction  of  the  gall- 
stone is  generally  found  to  happen  near  the  termination  of  the  duo- 
denum, or  in  the  upper  part  of  the  jejunum. 

In  obstruction  from  diseased  lymphatic  glands  in  the  neighbor- 
hood of  the  duodenum,  the  occlusion  sometimes  becomes  suddenly 
complete,  and  the  symptoms  are  those  of  internal  strangulation;  but 
more  frequently  the  pressure  is  less,  and  the  symptoms  are  those 
which  we  shall  presently  have  to  refer  to  in  connection  with  disease 
of  the  pancreas;  thus,  in  an  instance  of  femoral  hernia  after  the  in- 
testine had  been  returned,  the  symptoms  continued,  and  the  patient 
quickly  died.  The  third  portion  of  the  duodenum  was  then  found  to 
have  become  firmly  impacted  between  two  enlarged  glands. 

CASE  XCII.  Obstruction  from  Biliary  Calculus  in  the  upper  part  of  t'ie 
Jejunum,  thirty  inches  from  the  Pylorus — The  calculus  is  in  the  museum  of 
Guy's.  The  case  was  under  the  care  of  Ebenezer  Pye  Smith,  Esq.,  and  is 
recorded  in  the  '  Pathological  Transactions'  of  18f>4.  The  patient  was  a 
stout  woman,  net.  62.  She  had  good  health  till  three  months  before  death, 
when  she  suffered  slight  pain  in  the  right  hypochondrium,  which  continued 


DUODENUM.  271 

a  fortnight,  unaccompanied  by  sickness  or  prostration.  She  recovered,  but 
continued  her  usual  sedentary  habits  ;  five  days  before  death  she  began  to 
feel  sick,  and  vomited  bile  in  large  quantities;  the  urine  was  moderately 
secreted.  The  vomiting  increased  in  violence,  but  with  only  very  slight  pain 
in  the  abdomen  ;  on  the  fifth  day  she  became  comatose.  A  calculus  com- 
posed of  inspissated  bile,  and  measuring  four  and  a  half  inches  in  the  circum- 
ference of  its  long  by  two  and  a  half  in  the  circumference  of  its  short  axis, 
was  found  impacted  about  thirty  inches  from  the  pylorus.  There  was  much 
fibrous  tissue  on  the  under  surface  of  the  liver  ;  and  an  ulcerated  opening  ex- 
tended from  the  gall-bladder  into  the  duodenum,  below  the  bile-duct. 

The  case  just  recorded  of  gall-stone  with  hemorrhage  and  obstruc- 
tion is  of  a  somewhat  similar  kind.  An  interesting  case  is  recorded 
by  Dr.  T.  S.  Gray  in  the  '  Transactions  of  the  Clinical  Society  for 
1873,'  in  which  a  large  gall-stone  led  to  obstruction  and  stercoraceous 
vomiting,  but  was  subsequently  discharged,  and  the  patient,  a  man 
aged  40,  recovered. 

There  are  in  these  cases  three  symptoms  which  especially  deserve 
attention,  as  guiding  us  to  a  right  diagnosis,  when  viewed  in  connec- 
tion with  the  previous  history.  The  absence  of  abdominal  distension, 
the  early  period  at  which  vomiting  takes  place,  with  the  character 
of  the  ejected  matters,  and  the  diminution  in  the  quantity  of  urine 
which  is  voided. 

The  absence  of  distension  of  the  abdomen  is  an  important  sign  of 
occluded  intestine  in  the  early  part  of  its  course.  In  obstruction  of 
the  large  intestine,  or  even  at  the  lower  part  of  the  small,  the  abdo- 
men becomes  enormously  distended,  and  the  peristaltic  movements 
can  often  be  observed  in  spare  persons  through  the  parieties;  this  is 
especially  the  case  in  disease  of  the  sigmoid  flexure  of  the  colon. 
The  stoutness  of  the  patient  sometimes  renders  this  sign  less  observa- 
ble ;  again,  where  this  duodenal  obstruction  exists  with  hernia,  the 
diagnosis  must  necessarily  be  most  obscure.  As  to  vomiting,  it 
comes  on  very  early,  and  the  matters  rejected  are  bilious.  In  stran- 
gulation of  the  ileum,  and  obstruction  of  the  colon,  unless  irritating 
purgatives  are  given,  this  distressing  symptom  may  be  considerably 
postponed ;  and  when  it  does  take  place  and  is  continued,  the  mat- 
ters are  of  a  stercoraceous  character.  Still,  in  acute  peritonitis,  as 
from  perforation,  the  sudden  bilious  vomiting  may  greatly  mislead 
us.  Again,  very  violent  bilious  vomiting  sometimes  takes  place  in 
disease  of  the  stomach,  and  in  cerebral  disease ;  but  the  signs  of  ob- 
struction are  then  wanting. 

Gall-stone  produces  intense  pain  in  the  region  of  the  gall-bladder, 
accompanied  with  vomiting  and  constipation;  this  severe  character 
of  pain  we  do  not  find  in  intestinal  obstruction,  but  it  must  be  ac- 
knowledged, that  when  slow  ulcerative  absorption  has  taken  place 
between  the  walls  of  the  gall-bladder  and  the  duodenum,  a  calculus 
so  extruded  is  followed  by  less  severe  suffering  than  in  ordinary  cases 
of  biliary  calculus. 

A  very  interesting  case,  under  the  care  of  Dr.  Lever,  is  mentioned 
by  Dr.  Barlow  in  the  'Guy's  Exports,'  for  1844  :— The  patient  aged 
fifty-one  a  year  before  her  death  had  the  symptoms  of  gall-stone, 


272  DUODENUM. 

and  the  bowels  afterwards  became  constipated  ;  a  short  time  before 
her  death,  excessive  pain,  vomiting,  and  constipation  came  on,  v> -ith 
scanty  urine  and  collapsed  abdomen.  The  gall-bladder  and  duodenum 
were  firmly  adherent ;  the  two  upper  thirds  of  the  duodenum  were 
contracted,  thickened,  and  would  only  admit  a  common  quill ;  about 
the  centre  of  the  ileum  was  a  biliary  calculus  of  the  size  of  a  walnut, 
partially  sacculated. 

"With  regard  to  the  quantity  of  urine  excreted  being  a  sign  of  the 
seat  of  obstruction,  as  mentioned  in  the  paper  by  Dr.  Barlow,  just 
referred  to,  he  argues  that  the  quantity  of  urine  must  necessarily  be 
small,  from  the  diminished  fluid  brought  Avithin  the  range  of  the  ab- 
sorbing surface  of  the  portal  veins ;  and  thus  there  must  be  diminished 
supply  to  the  heart  and  kidneys;  but  there  is  often  a  large  quantity 
of  fluid  ejected  by  vomiting,  which  would  proportionately  lessen  the 
renal  secretion.  If  the  obstruction  be  incomplete,  or  low  down  in 
the  intestine,  the  kidneys  pour  out  a  larger  quantity,  and  the  vomit- 
ing is  also  less  severe. 

Dr.  Barlow  has,  in  the  paper  previously  cited,  dwelt  upon  the 
importance  of  bearing  in  mind,  that  in  ischuria  renalis,  violent  vomit- 
ing, constipation,  and  scanty  urine  are  sometimes  present. 

In  diseased  pancreas  the  obstruction  is  less  complete,  but  it  acts 
by  inducing  firm  adhesions  about  the  first  and  second  portions  of  the 
duodenum ;  and  pressure  is  also  exerted  by  the  increased  size  and 
hardness  of  the  pancreas,  and  by  infiltrated  glands.  The  symptoms 
resemble  those  of  obstructed  pylorus,  namely,  vomiting  several  hours 
after  food,  gradually  increasing  emaciation,  with  constipation;  and 
these  symptoms  are  slowly  developed  during  several  mouths.  A 
tumor  can  generally  be  felt  near  the  region  of  the  pylorus. 

The  following  very  interesting  case  was  regarded  as  one  of  cancer- 
ous disease  of  the  glands  in  the  neighborhood  of  the  pancreas,  and 
secondary  implication  of  the  stomach ;  for  the  vomiting  took  place 
three  or  four  hours  after  a  meal,  as  in  obstructive  disease  of  the 
pylorus  ;  and  the  general  symptoms  resembled  those  of  organic  gas- 
tric change. 

CASE  XCIII.  Disease  of  the  Pancreas.  Suppuration  and  Gangrene. 
Pressure  on  the  Duodenum. — James  P — ,  aet.  60,  by  occupation  a  publican, 
and  resident  at  Cambervvell,  was  admitted  under  my  care  on  July  4th,  1HG1. 
He  stated  that  he  had  always  enjoyed  good  health  till  four  months  prior  to 
admission,  when  he  was  suddenly  seized  with  severe  pain  in  the  region  of  the 
stomach,  and  with  vomiting.  The  vomiting  returned  at  intervals  of  three  or 
four  days,  and  came  on  several  hours  after  food.  Four  years  previously  he 
had  begun  to  feel  slight  pain  at  the  region  of  the  stomach,  winch  came  on 
every  three  or  four  months,  but  was  relieved  by  taking  a  little  cayenne 
pepper  with  brandy.  He  had  not  received  any  blow,  nor  had  he  sutf'civd 
from  any  haematemesis.  The  pain  was  situated  at  the  epigastric  and  umbili- 
cal regions,  and  extended  to  the  spine ;  it  was  of  an  acute  kind,  and  had  not 
the  gnawing  character  of  pain  often  described  by  patients  affected  with  ulcer 
of  the  stomach. 

On  admission  he  was  very  much  emaciated,  with  an  anxious  countenance, 
sallow  complexion,  and  sunken  eyes ;  his  skin  was  hot  and  dry,  and  he  com- 
plained greatly  of  thirst;  the  tongue  was  furred,  the  pulse  frequent  and  sharp, 


DUODENUM.  273 

the  respiration  normal;  he  had  slight  cough,  but  it  did  not  distress  him;  and 
there  was  no  evidence  of  thoracic  disease  by  percussion  nor  by  auscultation. 
The  abdomen  was  contracted  moderately,  except  at  the  lower  part  of  the 
epigastric  and  at  the  umbilical  region,  where  there  was  a  rounded  tumor, 
evident  on  visual  examination.  The  tumor  was  dull  and  tender  on  percus- 
sion; no  fluctuation  could  be  felt,  and  it  had  slight  pulsation  anteriorly  from 
contact  with  the  aorta,  but  no  general  aneurismal  thrill.  There  was  reso- 
nance between  the  tumor  and  the  liver,  as  well  as  between  the  tumor  and 
the  spleen ;  in  fact,  both  the  hypochondriac  regions  were  more  than  usually 
resonant.  Pressure  on  the  tumor  produced  a  feeling  of  nausea  ;  the  bowels 
were  constipated;  and  the  appetite  was  very  poor.  His  weakness  compelled 
him  to  remain  quietly  in  bed.  The  urine  was  high  colored  and  scanty,  and 
was  free  from  albumen.  Fluid  food  was  ordered,  and  soda-water  with  brandy, 
and  chloric  ether  n^x,  with  nitrate  of  bismuth  gr.  x  in  mucilage  mixture. 

July  5th — He  was  slightly  relieved  by  the  medicine,  but  the  vomiting  con- 
tinued ;  the  ejected  matters  consisted  of  deep-green  fluid,  containing  a  large 
quantity  of  mucus,  of  squamous  epithelium,  and  some  nucleated  cells  (from 
gastric  glands).  These  attacks  of  vomiting  distressed  him  greatly ;  every 
kind  of  food  was  rejected  at  once,  but  the  medicine  and  ice  partially  relieved 
his  distress ;  his  prostration,  however,  increased  ;  hiccough  distressed  him  ; 
and  he  had  an  offensive  taste  in  the  mouth. 

July  8th — He  was  extremely  restless  and  prostrate,  and  the  vomited  mat- 
ters were  of  very  deep-green  color.  At  0  P.  M.  he  was  suddenly  taken 
worse,  and  continued  in  great  pain  during  the  night.  At  7  A.M.  next 
morning  he  expired. 

Inspection  seven  hours  after  death — The  body  was  very  much  emaciated. 
The  thoracic  viscera  were  healthy,  excepting  old  pleuritic  adhesions.  The 
peritoneum  contained  some  dirty  gray  fluid,  and  had  in  some  parts  lost  its 
shining  smoothness;  the  intestines  were  slightly  distended.  The  sac  of  the 
lesser  omentum  was  distended  by  a  large  abscess,  which  had  constituted  the 
tumor  felt  during  life.  On  tracing  the  duodenum  upwards,  at  its  centre  was 
found  an  oedematous  portion  bulging  out;  and  containing  fluid  resembling 
that  in  the  peritoneum  ;  but  there  was  no  perforation.  By  dividing  the  peri- 
toneum between  the  stomach  and  the  colon,  an  abscess  was  opened ;  it  had 
dense  fibrous  walls,  about  two  lines  in  thickness,  in  some  parts  irregularly 
sinuous,  and  having  several  bands  on  its  walls,  the  remains  of  occluded  vessels. 
Above  and  partly  in  front  of  the  abscess  was  the  stomach  ;  below  was  the 
colon,  and  at  its  superior,  right,  and  inferior  parts  was  the  duodenum  greatly 
distended,  and  its  coil  enlarged.  The  abscess  contained  dirty  offensive  pus, 
and  at  its  posterior  part  was  a  black  slough  about  two  and  a  half  inches  in 
length  ;  some  concrete  yellow  matter  was  also  found  on  its  walls.  The  ab- 
scess rested  on  the  spine,  the  crura  of  the  diaphragm,  and  on  the  superior 
mesenteric  and  splenic  veins  as  they  formed  the  vena  port*.  It  extended 
on  the  left  to  the  spleen.  The  pancreas  for  two  to  three  inches  toward  the 
splenic  extremity  was  healthy,  but  the  rest  of  the  gland  was  in  a  sloughy 
state,  and  constituted  the  black  mass  found  at  the  floor  of  the  abscess.  The 
pancreatic  duct  existed  in  the  centre,  and  degenerating  gland  tissue  was  ob- 
served under  the  microscope.  The  gland  and  duct  were  separated  from  their 
duodenal  attachment.  The  common  bile-duct  was  healthy,  and  its  opening 
into  the  duodenum  was  free;  but  the  gall-bladder  contained  numerous  gall- 
stones about  the  size  of  peas.  The  liver  and  spleen  were  healthy.  The 
stomach  was  very  much  enlarged  and  distended ;  it  contained  tenacious  green 
mucus,  such  as  was  vomited  during  life ;  its  mucous  membrane  presented 
numerous  points  of  arborescent  injection,  so  al:o  that  of  the  duodenum ;  but 
18 


274  DUODENUM. 

no  direct  communication  with  the  abscess  could  be  found,  nor  any  ulceration 
of  the  surface. 

The  origin  of  the  disease  in  this  remarkable  case  could  not  be 
ascertained,  viz.,  whether  a  pancreatic  calculus  had  set  up  the  abscess, 
or  whether  inflammation  had  been  produced  in  the  cellular  tissue 
about  the  gland.  No  direct  blow  had  been  received,  and  the  disease 
slowly  advanced.  Acute  peritonitis,  from  the  transudation  of  offen- 
sive purulent  serum  into  the  general  cavity  of  the  peritoneum,  was 
the  cause  of  the  fatal  termination. 

Dr.  Bright  believed  that  the  fatty  motions  which  he  found  in  some 
of  these  cases  were  indicative  of  disease  of  the  pancreas,  but  this 
symptom  has  not  been  constantly  observed  in  pancreatic  disease, 
possibly  from  the  duct  being  only  partially  occluded. 

The  course  taken  by  hydatid  disease  of  the  liver  is  uncertain; 
sometimes  it  is  towards  the  surface,  and  a  rounded  tumor  is  then  felt 
on  the  anterior  abdominal  parietes;  or  it  extends  through  the  dia- 
phragm into  the  lungs.  In  a  case  under  the  care  of  Dr.  Rees,  in  Guy's, 
the  cyst  opened  into  the  duodenum.  Hydatids  were  both  vomited 
and  passed  by  stool,  and  the  former  symptom  was  very  severe.  The 
patient  was  exceedingly  ill,  and  a  friction  sound  was  audible  over 
the  seat  of  the  tumor,  evidently  from  local  peritonitis ;  the  patient 
steadily  improved  after  the  evacuation  of  the  hydatids  by  vomiting ; 
the  tumor  disappeared,  and  he  left  the  hospital;  but  after  a  few 
weeks  intense  peritonitis  came  on,  and  he  quickly  died.  The  re- 
mains of  hydatids  were  found  in  the  liver;  and  the  duodenum, 
colon,  liver  and  kidney,  were  firmly  united  by  adhesions.  A  large 
abscess  existed  between  these  structures,  and  had  led  to  the  fatal 
peritonitis.  No  communication  existed  between  the  liver  and  the 
colon ;  and  although  the  duodenum  at  its  second  part  was  firmly 
adherent,  no  direct  opening  could  be  found. 

The  patient  was  twenty-nine  years  of  age,  and  had  resided  at 
Twickenham ;  he  was  temperate  in  his  habits ;  for  nine  years  he 
had  suffered  from  so-called  "bilious  attacks,"  and  from  vomiting, 
with  slight  sallowness  of  the  skin  ;  five  years  previously  he  had  had 
severe  jaundice,  which  continued  for  three  weeks.  Eight  months 
before  admission  his  appetite  became  ravenous,  but  he  lost  strength 
and  became  emaciated ;  for  seven  weeks  he  had  been  confined  to  his 
bed  from  severe  pain  about  the  umbilical  region;  jaundice  came  on, 
but  disappeared,  and  was  followed  by  very  severe  pain  in  the  right 
hypochondriac  region,  extending  to  the  loins,  and  a  rounded  growth 
presented  itself  below  the  ribs  on  the  right  side. 

A  remarkable  instance  of  mechanical  obstruction  in  the  duodenum 
from  a  foreign  body,  is  recorded  by  Dr.  Blakeley  Brown,  in  the 
'Pathological  Transactions'  of  1851  and  1852  : — A  delicate  young 
woman,  aged  eighteen,  became  gradually  emaciated,  and  at  last  died 
from  peritonitis.  The  stomach,  duodenum,  and  upper  part  of  the 
jejunum,  contained  casts  composed -of  agglutinated  and  interwoven 
masses  of  string  and  hair. 

Gastric  Solution  of  Duodenum.  The  mucus  of  the  duodenum  is 
frequently  found  in  an  acid  condition  after  death,  which  is  probably 


DUODENUM.  275 

due  to  some  of  the  gastric  juice  slowly  gravitating  through  the  py- 
lorus; but  in  some  instances  the  pylorus  is  so  patulous,  that  gastric 
juice  readily  passes,  and  exerts  its  solvent  power  after  death  in  the 
same  manner  as  in  the  stomach.  Such  a  state  was  found  in  a  child 
who  died  under  my  care  in  Guy's. 

CASE  XCIV.  Perforation  of  Duodenum  after  Death  from  Solution  by 
Gastric  Juice — William  B — ,  get.  4,  was  admitted  July  16th,  185G,  and 
died  on  the  23d.  He  was  an  anaemic  child,  with  large  head  ;  on  admission 
he  was  in  a  semi-comatose  state,  and  the  pupils  were  widely  dilated ;  he  had 
occasional  vomiting,  but  no  convulsions  ;  six  weeks  previously  he  had  had 
measles,  and  one  week  afterwards hydrocephalus gradually  became  developed; 
he  was  in  an  almost  hopeless  condition  on  admission. 

Inspection  was  made  fourteen  hours  after  death.  The  arachnoid  was  cov- 
ered with  a  slight  layer  of  lymph,  so  as  to  give  it  a  greasy  appearance,  and 
at  the  base  of  the  brain  there  was  considerable  sub-arachnoid  effusion.  The 
ventricles  contained  two  ounces  of  fluid,  of  sp.  gr.  1001.  There  were  miliary 
tubercles  in  the  lungs  and  in  the  bronchial  glands. 

In  the  stomach  there  was  considerable  gastric  solution,  the  mucous  mem- 
brane being  destroyed  ;  but  in  the  duodenum  the  intestine  was  quite  divided, 
all  the  coats  destroyed,  and  the  end  of  the  first  portion  terminated  in  an  ir- 
regular ragged  margin.  The  contents  of  the  stomach  were  found  in  the 
peritoneal  cavity.  There  were  tubercles  in  the  mesenteric  glands,  and  an 
isolated  one  in  the  kidney. 


27(3 


CHAPTER    VIII. 

MUCO-ENTERITIS  AND  ENTERITIS. 

THERE  has  been  considerable  confusion  in  the  application  of  the 
term  enteritis;  Broussais  considered  it  to  be  inflammation  of  the 
colon,  Abercrombie  regarded  it  as  inflammation  of  the  peritoneal  and 
muscular  coats  of  the  intestine;  others,  again,  more  particularly  apply 
the  term  to  an  inflammatory  disease  of  the  small  intestine,  which 
commences  in  the  mucous  membrane,  and  extends  in  severe  cases, 
so  as  to  involve  all  the  coats  of  the  intestine,  even  its  peritoneal  in- 
vestment. These  latter  and  more  severe  instances  correspond  to  the 
enteritis  phlegmonodea  of  Cullen;  the  former,  when  the  mucous 
membrane  only  is  affected,  to  his  enteritis  erythematica. 

Watson,  Barlow,  and  others,  apply  the  term  only  to  the  more 
severe  cases  of  inflammation  of  all  the  coats,  but  we  shall  in  this 
chapter  also  consider  those  in  which  little  more  than  the  mucous 
membrane  is  affected,  called,  muco-enteritis,  and  closely  allied  to 
gastro-enterite  and  gastric  remittent  fever.  Dr.  Copland  describes 
glandular  enteritis,  and  ileo-colitis ;  the  former  we  consider  in  the 
remarks  on  strumous  disease  of  the  intestine  and  enteric  fever,  the 
latter  with  dysentery. 

Enteritis  manifests  itself  under  two  forms:  1.  That  involving  only 
the  mucous  membrane,  and  which  has  a  disposition  to  extend  in  the 
course  of  the  mucous  membrane — muco-enteritis  (this  state  may  be 
acute  or  chronic  and  catarrhal  in  character);1  and,  2.  That  in  which 
the  disease  extends  in  depth,  rather  than  on  the  surface,  and  impli- 
cates the  muscular,  and  peritoneal  coats,  and  the  connecting  tissues, 
whether  diphtheritic,  ulcerative,  or  phlegmonous  in  its  nature;  both 
forms  commence  in  the  mucous  membrane. 

In  hernia,  whether  external  or  internal,  acute  enteritis  is  set  up; 
and  there  may  be  symptoms  in  common  with  enteritis,  as  constipation, 
vomiting,  &c.,  but  the  pathology  and  treatment  of  the  two  diseases 
are  so  diverse  that  a  separate  consideration  of  them  is  required. 

It  would  be  difficult  to  draw  a  defined  separation  between  cases  of 
inflammatory  diarrhoea,  as  described  by  Dr.  West,  and  the  simplest 
forms  of  enteritis;  they  pass  the  one  into  the  other.  Diarrhoea, 
however,  is  not  a  constant  symptom  of  enteritis;  for  the  bowels  in 
the  latter  disease  are  frequently  constipated. 

Pathological  changes. — In  muco-enteritis  we  may  find  very  much 
less  change  than  had  been  anticipated.  Neither  ulceration  nor  con- 
gestion may  be  observed  throughout  the  whole  canal.  It  is  probable 

1  See  further  reference  to  catarrhal  inflammation  in  our  remarks  on  catarrhal  diar- 
rhoea and  catarrh  of  the  colon. 


MUCO-ENTERITIS    AND    ENTERITIS.  277 

that  the  injected  condition  has  in  these  instances,  like  erythema  of 
the  skin,  entirely  passed  away;  thus  also  some  of  the  most  severe 
forms  of  bronchitis  present  scarcely  any  morbid  appearance  of  the 
bronchial  tubes  themselves,  the  congestion  having  disappeared,  al- 
though the  altered  mucus  remains.  This  state  of  congestion  may, 
however,  have  caused  marked  symptoms  of  disease. 

In  catarrhal  inflammation,  a  change  in  the  character  of  the  secre- 
tion from  the  mucous  membrane  is  a  sure  indication  of  its  deviation 
from  the  normal  condition;  but,  unfortunately,  we  do  not  possess 
the  same  facility  for  the  examination  of  the  secretions,  from  the 
digestive  as  from  the  respiratory  mucous  membrane.  Adhesion  of 
a  thin  stratum  of  fecal  matter  is  an  indication  of  an  imperfect  secre- 
tion of  mucus;  or  a  lyrnph-like  exudation  takes  place;  this  exuda- 
tion resembles  the  diphtheritic  membrane  found  in  the  throat,  and 
it  consists  of  an  immense  number  of  granules  with  nuclei;  it  may 
sometimes  be  easily  scraped  off,  exposing  an  injected  surface  beneath ; 
in  other  instances  a  section  of  the  whole  membrane  shows  that  it  is 
firmly  united. 

The  mucus  which  is  found  in  the  intestine  presents  indications  of 
rapid  change  having  taken  place,  nuclei  and  elongated  cells  of  in- 
complete epithelium  being  found  in  great  abundance;  and  mucus  as 
well  as  pus  are  found  in  the  evacuations  during  life. 

Crystals  of  triple  phosphate  are  frequently  detected  on  the  surface 
of  the  mucous  membrane.  It  is  probable  that  in  many  instances 
this  is  a  post-mortem  change;  but  in  other  cases  we  find  such  crys- 
tals when  the  inspection  has  been  made  a  few  hours  after  death; 
and  they  probably  result  from  decomposition  of  the  mucus,  as  in 
the  urinary  bladder  after  chronic  inflammatory  action. 

The  solitary  glands  may  be  very  large  and  prominent,  a  state 
which  is  due  to  the  age  of  the  patient,  and  the  functional  activity  of 
these  structures,  or  to  the  excitement  of  morbid  action.  Sometimes 
these  glands  give  to  the  mucous  membrane  the  appearance  as  if 
sprinkled  over  with  fine  sand.  Small  aphthous  ulcers  sometimes 
exist,  the  ulceration  commencing  in  the  follicles;  these  ulcers  may 
lead  to  perforation  of  the  intestine,  as  in  a  case  recorded  among  the 
inspections  at  Guy's,  in  which  there  were  minute  ulcers  extending 
throughout  the  whole  of  the  small  and  large  intestine;  and  perfora- 
tions of  the  caecum  and  transverse  colon  had  led  to  fatal  peritonitis. 

Gray  discoloration  is  often  observed  around  the  solitary  follicles, 
or  it  is  more  general  in  character,  either  in  the  large  intestine,  in  the 
lower  parts  of  the  ileum,  or  even  in  the  duodenum.  This  state  con- 
sists in  the  deposit  of  pigment  in  the  membrane  in  contact  with  the 
vessels,  and  is  the  result  of  continued  congestion ;  it  apparently  fol- 
lows also  as  an  effect  of  muco-enteritis. 

The  most  intense  form  of  local  enteritis  exists  when  a  portion  of 
the  intestine  has  become  strangulated;  the  mucous  membrane  is 
then  swollen,  and  it  is  also  intensely  injected ;  portions  of  feces  and 
mucus  adhere  to  the  valvulse  conniventes,  or  the  whole  surface  of 
the  mucous  membrane  is  covered  by  a  thin  adherent  layer  of  granu- 
lar lymph ;  all  the  coats  of  the  intestine  become  thickened,  and  the 


278  MUCO-ENTERITIS    AXD    ENTERITIS. 

areolar  tissue  is  oedematous;  the  peritoneum  is  covered  by  lymph; 
it  is  intensely  congested  and  of  a  purple  or  slate  color,  or  even  gan- 
grenous. The  thickening  of  the  mucous  membrane  in  all  these 
cases  arises  from  the  presence  in  the  submucous  tissue  of  a  large 
number  of  cellular  elements  (pyoid),  and,  in  the  more  severe  cases, 
they  extend  between  the  muscular  fasciculi  and  reach  to  the  perito- 
neal coat. 

A  condition  closely  resembling  that  just  described  is  sometimes 
found  without  any  strangulation,  either  affecting  only  the  ileum,  or 
of  a  dysenteric  character,  and  involving  also  the  caecum  and  colon ; 
thus,  a  distended  and  congested  state  of  the  ileum  may  terminate 
suddenly,  as  if  there  had  been  a  constriction,  and  the  portion  of  small 
or  large  intestine  below  may  be  pale  and  contracted;  on  removing 
the  intestine,  the  apparent  constriction  ceases,  the  canal  becomes 
perfectly  free,  and  the  congestion  is  the  only  thing  that  marks  the 
obstruction.  There  has  been  much  discussion  whether  in  these  cases 
there  is  really  obstruction  by  a  twist  of  the  intestine,  by  a  spasmodic 
condition  of  the  contracted  part,  or  by  a  paralyzed  state  of  the  dis- 
tended one;  the  last  supposition  is  now  generally  regarded  as  the 
correct  explanation,  namely,  that  the  inflamed  intestine  becomes 
distended,  and  its  peristaltic  contraction  enfeebled,  so  that  at  last  it 
is  unable  to  contract  upon  and  propel  its  contents.  The  abrupt 
termination  may  be  determined  by  a  cicatrix,  by  slight  peritoneal 
adhesion,  or  by  old  disease  of  the  mesentric  glands.  These  instances 
closely  resemble  true  ileus  from  strangulation  or  from  other  mechani- 
cal cause. 

Ulceration  and  sloughing,  or  gangrene,  generally  follow  this  form 
of  enteritis;  but,  although  in  hernia  and  internal  strangulation  the 
gangrenous  part  is  at  the  seat  of  constriction,  this  is  not  always  the 
case  in  obstruction  from  other  causes;  in  obstructive  disease  of  the 
sigmoid  flexure,  ulceration  takes  place  above  the  seat  of  the  obstruc- 
tion ;  but  the  most  acute  inflammation  and  ulceration  will  often  be 
found  in  the  ileum,  caecum,  and  ascending  colon.  The  inflamed 
mucous  membrane  in  these  parts  gives  way  from  the  enormous 
distension;  numerous  ulcers,  arranged  in  transverse  lines,  are  closely 
set  together  in  the  ileum  and  caecum,  and  some  of  these  occasionally 
extend  through  the  peritoneum. 

Obstruction  of  the  mesenteric  vessels  usually  takes  place  in  cases 
of  internal  hernia ;  but  it  is  probable  that  obstruction  of  these  vessels 
is  sometimes  the  cause  of  the  change  rather  than  the  effect.  Intense 
engorgement  of  a  few  inches  of  intestine  may  be  found,  and  the 
mucous  membrane  may  be  almost  in  a  sloughing  state,  without  any 
symptom  having  been  manifested  during  life,  and  without  any  ob- 
struction being  present  after  death.  In  such  cases  a  thrombus  has 
probably  formed,  or  an  embolus  has  obstructed  the  mesenteric  vessels 
connected  with  the  part,  and  has  led  to  changes  in  the  nutrition  of 
the  intestinal  coats. 

In  inflammation  of  the  mucous  membranes  there  is  a  great  ten- 
dency to  the  extension  of  the  disease  by  continuity  of  structure. 
Sometimes  the  alimentary  canal,  in  its  whole  tract,  appears  to  be 


MUCO-ENTERITIS    AND    ENTERITIS.  279 

inflamed;  at  other  times  the  disease  commences  in  one  part,  and 
extends  from  that  as  from  a  centre.  Inflammation  of  the  colon  will 
pass  into  the  ileum ;  that  of  the  ileum  into  the  large  intestine,  as 
well  as  into  the  jejunum,  duodenum,  and  stomach.  In  enteritis  the 
small  intestine  only  may  be  affected,  or  the  cgecum  and  colon  may 
be  also  implicated.  Broussais1  speaks  of  this  extension  of  disease ; 
but,  though  we  are  not  disposed  to  agree  with  his  opinions,  we  must', 
I  think,  acknowledge  the  truth  of  the  frequent  extension  of  disease 
to  contiguous  and  continuous  structures;  and  this  is  probably  as 
true  of  the  mucous  membrane  as  it  is  of  the  skin,  as  exemplified  in 
erysipelas. 

These  changes  in  the  mucous  membrane  of  the  small  intestine, 
even  though  only  of  a  catarrhal  character,  may  be  followed  by 
wasting  of  the  mucous  membrane,  and  in  some  cases  the  atrophy  of 
all  the  coats  of  the  intestine  is  so  extreme  that  together  they  are 
scarcely  thicker  than  tissue  paper.  In  others  the  impairment  of 
nutrition  is  followed,  especially  in  young  subjects,  by  the  deposition 
of  tubercular  disease  in  the  mucous  membrane,  involving  first  the 
follicles  and  lymphatic  vessels  of  the  bowel ;  to  these  cases  we  shall 
again  have  to  refer  in  speaking  of  strumous  disease.  Lardaceous 
disease  of  the  intestine  may  also  be  associated  with  symptoms  of 
muco-enteritis;  in  these  instances  the  mucous  membrane  is  thickened 
and  has  a  sodden  appearance,  sometimes  it  is  ulcerated  ;  the  villi  and 
the  minute  capillary  arteries  are  found  to  be  thickened,  so  also  those 
surrounding  the  sacculi  of  Peyer's  glands,  and  the  membrane  under 
examination  is  at  once  changed  by  the  action  of  iodine.  These  forms 
of  disease  are  generally  found  with  lardaceous  disease  of  other  organs, 
as  of  the  liver,  the  spleen,  or  the  kidneys. 

We  shall  first  consider  enteritis  in  the  form  of  muco-enteritis,  \ 
enteritis  erythematica  or  catarrhal  inflammation?     This  is  very  fre-  \ 
quent  among  children  during  dentition  or  weaning,  and  after  the 
exanthemata ;  but  in  many  cases  of  infantile  diarrhoea  and  colic  a 
more  transient  condition  of  congestion  is  set  up,  the  indications  of 
which  are  twisting  pain  in  the  bowels,  and  the  evacuation  of  watery 
or  green  motions,  with  general  fretfulness,  &c. ;  these  symptoms  pass 
away  in  a  very  short  time,  and  they  arise  from  hyperaemia  rather 
than  from  true  inflammation  of  the  mucous  membrane. 

In  muco-enteritis  a  child  is  found  to  be  fretful,  without  its  usual 
playfulness  and  mirth.  The  lips  are  dry,  and  the  little  patient  has 
a  circumscribed  flush  on  one  or  other  cheek ;  the  skin  is  dry  or 
roughened ;  the  abdomen  is  somewhat  enlarged,  or  considerably  dis- 
tended and  tympanitic,  and  varies  in  the  amount  of  tenderness,  but 
the  restlessness  of  the  child  causes  it  to  cry  when  no  pain  is  pro- 
duced ;  it  is  unwilling  to  be  disturbed  ;  the  appetite  is  irregular  and 
capricious,  either  craving  for  cooling  drinks,  as  cold  water,  or  for 

1  Broussais,  '  Phlegmasies  Chroniques.' 

*  This  term  is  used  in  a  less  extended  sense  than  that  of  German  pathologist?,  who 
include  under  the  word  catarrh  every  form  of  inflammatory  affection  of  the  mucous 
surface. 


280  MUCO-ENTERITIS    AND    ENTERITIS. 

unsuitable  food,  which  is  oftentimes  the  cause  of  the  malady.  The 
bowels  are  irregular,  ether  constipated  for  several  days,  or  there 
may  be  diarrhoea ;  the  motions  are  offensive  and  pale,  or  greenish 
in  color,  or  the  evacuations  consist  of  slimy  mucus,  or  of  food  scarcely 
changed,  and  these  conditions  may  alternate  the  one  with  the  other; 
the  tongue  has  a  whitish  fur,  and  its  substance  or  papillae  are  often 
much  injected  ;  vomiting  may  easily  be  induced,  and  probably  arises 
from  the  extension  of  the  mischief  to  the  stomach,  when  the  disease 
is  called  gastro-enteritis.  In  the  evening  the  child  becomes  still 
more  restless,  the  skin  is  hot,  and  even  pungent ;  the  temperature 
101°  to  103 3 ;  the  sleep  is  disturbed,  and  accompanied  with  grinding 
of  the  teeth  or  starting,  and  the  child  often  awakes  alarmed;  in  the 
morning  the  febrile  disturbance  is  less,  and  it  may  be  cheerful  and 
playful. 

This  aggregation  of  symptoms  constitutes  the  so-called  gastric 
remittent  or  infantile  remittent  fever,  and  many  look  upon  it  in  the 
same  light  as  enteric  fever,  considering  that  the  inflammatory  con- 
dition of  the  intestine  is  a  concomitant,  not  the  essential  part,  of  the 
disease.  This  is,  I  think,  incorrect;  the  intestinal  disturbance  is 
the  source  and  the  cause  of  the  continuance  and  extension  of  the 
disease,  and  not,  as  in  enteric  fever,  the  manifestation  of  a  previously 
existing  and  general  condition. 

It  is  maintained  by  some  authorities,  such  as  West,  Eilliet,  and 
Barthez,  that  all  these  forms  of  disease  are  essentially  enteric  fever, 
but  although  there  is  febrile  excitement,  elevation  of  temperature, 
delirium,  red  and  glazed  tongue,  &c.,  we  do  not  find  any  rose  spots; 
the  duration  of  the  disease  is  different,  sometimes  indefinitely  pro- 
longed, at  other  times  passing  off  in  a  few  days.  Whilst,  in  the  one 
we  have  symptoms  due  to  the  reception  of  a  specific  drain  poison,  in 
the  other  we  have  no  more  than  can  be  accounted  for  by  simple  in- 
testinal inflammation,  the  same  difference  as  between  acute  derma- 
titis and  a  specific  exanthem. 

It  is  also  true  that  other  blood  poisons,  as  pyaemia,  may  produce 
intestinal  lesions,  but  these  could  not  be  mistaken  for  enteric  fever. 
When  the  symptoms  persist  severely  for  several  weeks  great  pros- 
tration ensues ;  the  child  wastes  sometimes  to  an  extreme  degree,  it 
appears  haggard  and  aged,  the  lips  have  dry  sordes  upon  them, 
the  tongue  is  more  injected,  and  often  aphthous.  There  is  less  re- 
mission in  the  morning ;  the  child  will  scarcely  sleep  at  all,  or,  in 
very  young  children,  allow  itself  to  be  taken  from  the  arms  of  its 
nurse  ;  the  diarrhoea  increases,  watery  evacuations  are  discharged  or 
food  unchanged  is  passed  a  short  time  after  it  has  been  taken ;  the 
pulse  becomes  very  rapid,  the  eyes  are  half  closed,  and  the  child  dies 
from  exhaustion,  almost  before  the  nurse  is  aware  of  any  change ; 
or  the  brain  becomes  oppressed,  and  a  drowsy,  torpid  condition,  or 
convulsions  sometimes  precede  death.  The  convulsions  and  coma, 
to  which  we  refer  as  coming  on  at  the  close  of  this  intestinal  condi- 
tion, are  closely  allied  to  those  produced  by  exhaustion,  as  in  the 
hydlrencephaloid  disease  of  Dr.  Marshall  Hall. 

Muco-enteritis  is  frequently  followed  by  tympanitis,  and  by  stru- 


MUCO-ENTERITIS    AND    ENTEKITIS.  281 

mous  diseases  of  the  peritoneum,  or  of  the  mesenteric  glands.  In 
such  cases,  although  the  more  prominent  symptoms  of  vomiting  and 
purging  subside,  the  child  remains  wasted,  the  abdomen  enlarges,  the 
appetite  becomes  ravenous,  and  exhaustion  steadily  progresses  to  a 
fatal  termination.  (See  Strumous  Disease.) 

In  young  persons  we  sometimes  find  a  state  of  muco-enteritis 
similar  to  that  described,  but  without  phthisis  or  tubercular  disease; 
the  eyes  are  sunken  and  bright,  the  lips  parched,  the  tongue  exceed- 
ingly injected,  and  beef  like  ;  the  cheek  is  occasionally  flushed  by  a 
circumscribed  patch  on  one  or  other  side ;  the  pulse  is  compressible, 
but  frequent ;  the  skin  is  at  one  time  dry,  at  another  perspiring ; 
there  is  thirst,  generally  with  loss  of  appetite,  and  sometimes  with 
great  irritability  of  the  stomach ;  the  bowels  are  constipated,  or 
diarrhoea  alternates  with  constipation.  The  urine  is  scanty  and  high 
colored.  This  condition  may  persist  for  many  weeks,  with  gradually 
increasing  exhaustion,  and  in  some  cases  it  terminates  fatally;  in  very 
many  instances  it  yields  to  judicious  treatment,  but  there  is  great 
danger  of  relapse.  In  young  women  this  state  is  sometimes  asso- 
ciated with  painful  or  deficient  menstruation,  or  with  leucorrhoea ; 
and  it  may  be  accompanied  with  severe  neuralgic  pain  in  the  abdo- 
minal parietes,  and  below  the  mammae.  This  neuralgia  occasionally 
leads  to  a  more  unfavorable  prognosis  than  the  case  warrants. 

The  second  form  of  enteritis  is  more  severe,  and  all  the  coats  of  the 
intestine  are  involved.  The  symptoms  are  exceedingly  acute,  and 
too  frequently  advance  to  a  fatal  termination  with  great  rapidity ; 
or  they  may  be  extended  over  many  weeks  or  months.  Severe  pain 
is  generally  present,  which  has  more  or  less  of  a  paroxysmal  char- 
acter, and  is  accompanied  with  great  tenderness  and  distension  of 
the  abdomen;  there  is  frequently  vomiting  of  bilious  fluid,  and  the 
bowels  are  often  constipated;  the  pulse  is  small,  wiry,  and  sometimes 
compressible,  the  tongue  is  partially  furred,  the  patient  lies  on  the 
back  with  the  legs  drawn  up,  as  in  acute  peritonitis,  and  prostration 
may  rapidly  ensue  ;  or,  whilst  the  more  severe  symptoms  subside, 
the  tongue'becomes  dry,  red,  and  glazed,  the  bowels  loose,  and  the 
strength  is  gradually  undermined  ;  or  again,  the  convalescence  may 
be  as  rapid  as  the  occurrence  of  the  symptoms.  In  these  conditions 
the  mind  is  generally  perfectly  clear. 

Several  instances'  which  have  come  under  my  own  observation 
will  illustrate  the  disease. 

CASE  XCV.     Acute  Enteritis A  child  about  seven  years  of  age.  after 

eating  freely  of  raw  apples,  was  seized  with  pain  in  the  abdomen  around  the 
umbilicus ;  the  bowels  were  constipated ;  the  abdomen  was  tender  and  dis- 
tended ;  the  countenance  was  expressive  of  much  distress ;  the  pulse  was 
rapid  ;  the  tongue  had  a  slight  fur  upon  it.  The  constipation  continued;  the 
abdomen  became  more  tender  and  distended,  and  the  child  was  found  tying 
on  its  back  in  severe  pain,  with  the  legs  drawn  up,  and  with  occasional 
vomiting.  This  state  continued  for  several  days  ;  the  bowels  were  then  freely 
acted  upon  ;  but  the  child  became  prostrate,  and  shortly  died,  four  or  five 
days  from  the  commencement  of  the  disease.  On  owning  the  abdomen,  the 
intestines  were  found  much  distended  with  flatus ;  the  peritoneal  surface  wad 


282  MUCO-ENTERITIS    AND    ENTERITIS. 

intensely  injected  where  the  coils  were  in  contact,  and  was  covered  with 
lymph.  The  mucous  membrane  of  the  small  intestine  was  congested,  and 
portions  of  undigested  apples  were  found  in  the  intestine. 

The  inflammation  had  been  set  up  by  crude  undigested  food ;  it 
extended  rapidly  from  the  mucus  to  the  muscular  and  connecting 
tissues,  and  to  the  peritoneum.  The  inflamed  intestine  was  unable 
to  propel  its  contents,  and  hence  the  constipation ;  and  sometimes 
the  constipation  is  so  marked,  that  it  is  the  most  prominent  symp- 
tom. The  severe  pain  in  this  form  of  enteritis  contrasts  with  the 
absence  of  it  where  the  mucous  membrane  only  is  affected. 

The  symptoms  in  other  instances  closely  resemble  those  conse- 
quent upon  mechanical  obstruction. 

CASE  XCVI.  Enteritis  simulating  Mechanical  Obstruction TIenry 

V — ,  act.  17,  was  admitted  into  Guy's  Hospital  in  1850.  He  was  a  tall,  thin 
lad,  who  had  been  employed  in  a  tobaconist's  shop  ;  and  a  week  before  ad- 
mission he  had  had  diarrhoea,  which  had  been  checked  by  an  opium  pill. 
The  day  before  admission  he  felt  well,  and  whilst  walking  out  of  doors  he 
ate  some  apples  and  cherries ;  a  few  hours  afterwards  severe  pain  in  the 
abdomen  came  on.  Some  rhubarb,  with  compound  chalk  powder  and  opium, 
was  prescribed;  the  bowels  were  opened  twice  during  the  night ;  but  at  seven 
in  the  morning  severe  pain  in  the  abdomen  returned ;  his  countenance  was 
then  expressive  of  great  distress  ;  the  eyes  were  sunken,  and  the  bowels  were 
confined  ;  the  tongue  was  furred  and  clammy  ;  he  was  rolling  himself  from 
one  side  of  the  bed  to  the  other,  from  the  intensity  of  the  pain  ;  the  recti 
muscles  were  rigid,  but  pressure  could  be  borne  ;  an  emetic  was  administered, 
and  some  undigested  apples  and  cherries  were  vomited.  Calomel  gr.  v.  with 
opium  gr.  iss,  were  given,  but  were  at  once  returned  ;  a  turpentine  injection 
was  then  administered.  Vomiting  then  came  on,  at  first  of  bilious,  after- 
wards of  stercoraceous  fluid ;  the  injection  brought  away  some  scybalous 
matter,  but  without  relief  to  the  pain.  His  pulse  became  exceedingly  rapid, 
and  he  died  at  eleven  the  next  morning,  about  thirty-six  hours  from  the  com- 
mencement of  the  attack. 

On  inspection,  the  intestines  were  found  to  be  very  much  distended ;  the 
peritoneum  was  injected,  and  delicate  portions  of  lymph  passed  between  the 
coils;  on  turning  aside  the  small  intestines,  the  ctvcum,  colon,  and  about 
three  feet  of  ileum  were  found  collapsed,  pale,  and  empty  ;  at  this  point  there 
was  a  sudden  cessation  of  the  intense  congestion  and  distension,  giving  the 
appearance  of  constriction;  but  no  constriction  nor  twist  could  be  detected; 
the  mesentery,  however,  attached  to  this  part,  and  connected  witli  the  hist 
lumbar  vertebra,  contained  several  hard  and  calcareous  glands,  and  appeared 
slightly  contracted;  on  raising  the  intestine,  and  placing  it  in  a  straight  line, 
air  at  once  passed,  and  the  constriction  disappeared.  The  intestine  was  full 
of  pale  yellow  fluid  feces,  and  contained  some  undigested  matter;  no  uicera- 
tion  existed,  and  the  other  viscera  were  healthy. 

In  this  case  severe  colic  came  on  after  taking  indigestible  food; 
inflammation  of  the  mucous  membrane  of  the  small  intestine  was 
produced;  this  extended  to  the  muscular  and  peritoneal  coats,  and 
was  followed  by  intense  pain,  by  distension,  and  by  vomiting.  It 
appeared  that  the  slight  interference  with  the  movement  of  the 
ileum  opposite  to  the  calcareous  mesenteric  glands  led  to  the  limita- 
tion of  the  disease  at  that  part,  and  that  over-distension  following 


MUCO-ENTERITIS    AND    ENTERITIS.  283 

inflammation  was  the  principal  cause  of  the  obstruction.  The  abdo- 
men for  several  hours  was  tolerant  of  pressure,  and  the  symptoms 
of  peritonitis  came  on  later;  could  the  enteritis  have  been  subdued, 
the  obstruction  would  probably  have  disappeared. 

The  following  case  is  one  in  which  the  most  acute  enteritis  pro- 
duced scarcely  any  symptom ;  the  patient  was  semi-comatose;  but 
it  is  closely  allied  to  cases  in  which  local  enteritis  is  apparently  set 
up  by  obstruction  of  the  vessels.1 

CASE  XCVII.    Sloughing  Ileum.      Thrombosis  of  the  Mesenteric  Veins. 

Peritonitis.    Chronic  Tubal  Nephritis.   Lobular  Pneumonia Thomas  C , 

set.  43,  was  admitted  into  Guy's  Hospital,  December  7th,  1853,  and  died 
December  31st.  By  trade  he  was  a  sailmaker,  and  during  the  last  two  years 
of  his  life  had  been  very  intemperate.  He  was  admitted  with  anasarca,  and 
coagulable  urine ;  diarrhoea  and  wasting  came  on,  and  before  death  lie  passed 
into  a  semi-comatose  condition.  The  inspection  was  made  forty-seven  hours 
after  death.  The  body  was  spare  and  pallid;  the  lungs  were  very  redematous, 
and  some  lobules  were  softened  and  breaking  down.  Abdomen The  intes- 
tines were  distended ;  there  was  general  peritonitis,  but  only  slight  injection 
of  the  peritoneum  at  the  edges  which  were  in  contact;  eight  incites  from  the 
ileo-cagcal  valve,  the  peritoneal  surface  of  the  intestine  for  several  inches  was 
of  a  dark  gray  color,  as  if  on  the  point  of  sloughing;  but  there  was  no  con- 
striction nor  strangulation,  nor  had  there  been  any  symptom  of  it  during  life. 
The  mucous  membrane  at  the  lower  part  of  the  ileum  was  in  a  sloughing 
condition,  but  this  diseased  portion  was  defined,  and  intensely  congested  at 
the  margin;  the  slough  was  thin,  but  it  affected  the  whole  of  the  mucous 
membrane,  and  was  not  confined  to  Peyer's  glands;  the  mesenteric  veins  were 
Jilted  with  clot.  The  left  lobe  of  the  liver  was  wasted,  forming  a  fibrous 
mass,  and  was  white  in  color,  probably  syphilitic;  the  remaining  part  of  the 
gland  was  fatty.  The  kidneys  were  large  and  white. 

In  this  patient  the  disease  of  the  kidney  had  led  to  unemic  poison- 
ing, and  to  the  semi-comatose  condition;  hence  the  non-complaint  of 
pain  in  the  severe  peritonitis  which  ensued.  There  is  great  dispo- 
sition in  uraemia  to  serous  inflammation  of  the  pleura,  pericardium, 
and  peritoneum;  but  it  is  rare  to  find  such  a  state  of  acute  inflam- 
mation as  that  described  in  this  case,  which  was  probably  secondary 
to  thrombosis  of  the  mesenteric  vein. 

Diagnosis. — Correct  diagnosis  is  very  important  in  enteritis,  other- 
wise valuable  time  may  be  lost,  and  such  aid  as  might  have  been  of 
essential  service  may  be  neglected. 

Hernia,  external  or  internal,  intussusception  and  mechanical  ob- 
struction from  any  cause,  may  be  confounded  with  enteritis  arising 
from  simple  inflammation. 

It  is  well  always  to  examine  the  ordinary  positions  of  external 
hernia;  many  mistakes  would  have  been  avoided  by  this  simple 
means.  In  internal  strangulation  the  pain  generally  comes  on  after 
sudden  muscular  movements  or  after  exertion  of  the  strength ;  the 
patients  often  affirm  that  until  the  time  of  sudden  exertion  they 
enjoyed  comfortable  health,  then  something  seemed  to  give  way,  or 

1  See  an  interesting  case  recorded  in  the  '  Path.  Trans.,'  vol.  xxvii,  p.  124,  of  acute 
thrombosis  of  the  superior  mesenteric  and  portal  veins,  by  Dr.  Hilton  Fagge. 


284  MUCO-ENTERITIS    AND    ENTERITIS. 

there  was  a  "catch,"  and  fixed  pain  was  felt,  from  which  the  subse- 
quent pain  radiated;  the  seat  of  pain,  however,  does  not  necessarily 
indicate  the  seat  of  obstruction,  as  found  after  death;  because  dis- 
tension and  the  movement  of  viscera  produce  much  alteration  in  the 
position  of  the  intestine.  After  the  sudden  onset  of  pain,  constipa- 
tion and  vomiting  with  varied  degrees  of  severity  come  on,  till  pros- 
tration, collapse,  and  death  ensue;  and  the  rapidity  of  the  symptoms 
may  be  as  great  as  in  external  hernia.  We  do  not  observe  this 
fixity  of  pain  in  enteritis,  although  it  may  be  at  first  localized  to  a 
comparatively  small  space. 

In  internal  obstruction  without  strangulation,  we  often  find  pre- 
vious constipation,  and  the  commencement  of  the  attack  is  slower, 
the  pain  being  sometimes  very  slight  till  towards  the  close  of  the 
malady. 

In  intussusception  the  sudden  severe  pain  is  very  different  from 
that  of  enteritis,  and  is  more  likely  to  be  confounded  with  simple 
colic.  When  the  symptoms  of  obstruction  from  intussusception  be- 
come developed,  an  elongated  tumor  can  generally  be  felt,  and  the 
discharge  of  bloody  mucus  is  often  observed  ;  the  value  of  this  diag- 
nostic indication  has  been  shown  by  Mr.  Gorham.1  In  enteritis  it 
is  very  important  carefully  to  ascertain  the  symptoms  which  marked 
the  onset  of  the  disease.  In  a  case  of  chronic  intussusception,  where 
there  was  occasional  diarrhoea  with  severe  colic  in  a  boy  of  fourteen 
years,  the  discharge  simulated  enteritis  and  a  suspicion  of  irritant 
poison  was  entertained.  (See  "  Intussusception.") 

It  is  difficult  to  distinguish  some  cases  of  chronic  poisoning,  or  even 
of  acute  poisoning,  from  enteritis  arising  from  other  causes.  In  these 
instances,  inflammation  of  the  mucous  membrane  is  produced.  I 
may  refer  to  cases  of  chronic  poisoning  by  arsenic ;  the  vomiting  is 
often  very  severe,  and  the  irritability  of  the  stomach  a  prominent 
symptom,  but  the  vomited  matter  is  never  stercoraceous ;  the  ab- 
domen is  generally  less  tender  than  in  the  worst  cases  of  enteritis ; 
in  doubtful  cases  we  must  be  guided  by  the  concomitant  symptoms 
and  by  the  analysis  of  the  vomited  matters.  In  the  enteritis  from 
crude  indigestible  food  and  irritants,  as  some  forms  of  mushrooms, 
the  symptoms  may  be  very  similar  to  those  consequent  on  ordinary 
poisons,  so  that  we  may  be  unable  to  distinguish  the  one  from  the 
other. 

In  simple  colic  there  is  less  difficulty ;  here  is  absence  of  tender- 
ness, and  the  pain  may  be  actually  relieved  by  pressure. 

In  peritonitis,  suddenly  induced  by  perforated  intestine,  the  col- 
lapse is  greater ;  the  abdomen  becomes  exquisitely  tender  and  tyin- 
panitic;  but  vomiting  is  not  generally  produced,  unless  the  peritoneal 
surface  and  other  coats  of  the  stomach  become  involved.  From 
whatever  cause  enteritis  is  induced,  peritonitis  is  a  very  common 
result;  and  the  muscular  coat  being  implicated,  the  peristaltic  action 
is  by  a  wise  provision  checked,  and  the  bowels  become  constipated. 

In  hysteria,  we  sometimes  find  tympanitis  with  constipation,  with 

»  'Guy's  Reports,'  1838,  p.  300. 


MUCO-ENTERITIS    AND    ENTERITIS.  285 

irritable  stomach,  and  with  pain  in  the  abdomen ;  and  these  symp- 
toms might,  by  carelessness,  be  mistaken  for  acute  inflammation. 
The  expression  of  countenance  is  not  that  of  severe  abdominal  dis- 
ease ;  the  vomiting  may  be  induced  by  anything  being  put  into  the 
stomach,  but  it  disappears  at  other  times.  The  pain  is  superficial 
and  the  abdomen  is  tolerant  of  continued  pressure,  unless  there  be 
inflammatory  disease  of  the  ovaries.  There  is  generally  leucorrhoea, 
with  painful  or  disordered  menstruation ;  but  the  patient  often  re- 
mains in  a  tolerably  nourished  condition. 

Ischuria  renalis.—Dr.  Barlow  has  pointed  out  the  importance  of 
bearing  in  mind  the  sympathetic  symptoms  connected  with  disease 
of  the  kidneys.  In  suppression  of  the  urine,  vomiting  and  constipa- 
tion often  exist ;  but  the  cerebral  oppression  is  generally  very  marked, 
and  the  examination  of  the  urine  (drawn  off  by  catheter,  if  none  can 
be  passed)  would  at  once  decide  the  character  of  the  complaint,  if 
there  be  any  obscurity.  A  temporary  ischuria  renalis  may  exist 
in  other  abdominal  diseases  and  even  in  mere  flatulent  distension.1 

Cerebral  disease. — It  is  not  unfrequent,  as  we  have  before  noticed, 
to  find  vomiting  present  as  a  symptom  of  disease  of  the  brain,  and 
then  also  associated  with  constipation  ;  but  there  are  some  peculiari- 
ties in  this  state  which  distinguish  it  from  enteritis  and  mechanical 
obstruction.  There  is  no  pain  or  distension  about  the  abdomen ;  the 
tongue,  the  countenance,  and  the  other  symptoms  of  disease  are  dif- 
ferent. In  young  children  it  is  sometimes  difficult  to  distinguish 
rnuco-enteritis  from  true  hydrocephalus  ;  there  is  irritability  of  the 
stomach  in  both,  with  perhaps  diarrhoea,  heat  of  skin,  startings  in 
the  sleep,  loss  of  appetite,  unwillingness  to  be  disturbed,  &c. ;  but 
in  the  former,  the  abdomen  is  more  distended,  in  the  latter  it  is  col- 
lapsed ;  the  tongue  is  injected,  arid  furred  in  the  one  case,  but  clean 
in  the  other.  In  hydrocephalus  also  there  is  greater  pain  in  the 
head,  or  drowsiness ;  there  is  disturbance  of  the  pupils,  which  are 
contracted,  or  in  the  later  stages  widely  dilated,  with  strabismus; 
and  the  fontanelles  become  distended  ;  the  vomiting  in  hydroce- 
phalus is  often  induced  by  only  raising  the  body  from  the  recumbent 
posture.  In  the  exhaustion  which  occasionally  follows  severe  diar- 
rhoea, or  muco-enteritis  in  infants,  a  series  of  symptoms,  resembling 
hydrocephalus,  or,  as  they  have  been  called,  hydnvncephaloid  disease, 
supervenes ;  these,  however,  are  very  different  from  true  hydroce- 
phalus ;  they  should  be  borne  in  mind,  lest  the  effect  of  exhausting 
disease  be  misinterpreted ;  in  these  cases  we  have  the  half-closed 
eye,  the  emaciated  expression,  diarrhoea,  collapsed  fontanelle ;  and 
the  early  symptoms  are  seen  to  commence  in  abdominal,  not  in  cere- 
bral disease. 

Causes. — The  ordinary  causes  of  enteritis  are  improper  or  indi- 
gestible food ;  this  is  especially  the  case  in  infants  and  children  in 
whom  the  disease  is  set  up  during  dentition  or  weaning,  or  after  ex- 
anthems,  especially  measles.  Exposure  to  cold  or  wet,  sleeping  in 
damp  beds,  or  in  the  open  air,  may  induce  it ;  violent  and  sudden 

1  Boyd,  'Edin.  Med.  Journal,'  1873,  "On  Infantile  Enteralgia." 


286  MUCO-ENTERITIS    AND    ENTERITIS. 

contortions  of  the  body,  excessive  muscular  exercise,  as  in  walking, 
are  other  causes.  It  may  be  associated  with  acute  disease  of  the 
lung,  so  also,  with  mechanical  obstruction,  however  produced, 
whether  by  hernia,  intussusception,  internal  strangulation,  tumors, 
&c.,  and,  lastly,  with  poisoned  conditions  of  the  blood,  as  pyajmia. 

Proynosis. — The  unfavorable  symptoms  of  enteritis  are  the  long 
persistence  of  the  disease,  emaciation,  the  development  of  peritonitis, 
distension  of  the  abdomen,  hiccough,  prostration  of  strength,  irregu- 
lar pulse,  a  haggard  and  anxious  expression,  sunken  eye ;  or,  after 
constipation  of  an  obstinate  character,  the  onset  of  severe  diarrhoaa, 
consisting  of  thin  offensive  or  serous  mucus;  also,  partial  sweats, 
inability  to  take  food,  persistent  beef-like  tongue. 

In  muco  enteritis,  the  continuance  of  diarrhoea,  thin  serous  evacua- 
tions like  the  washing  of  beef,  great  exhaustion  of  the  patient,  ex- 
ceedingly rapid  pulse,  and  convulsions,  are  the  precursors  of  a  fatal 
termination. 

Enteritis  is  less  amenable  to  treatment  when  there  is  a  strurnous 
diathesis ;  the  mesenteric  glands  are  prone  to  become  congested, 
swollen,  and  infiltrated;  and  the  patient  gradually  becomes  ex- 
hausted, or  strumous  disease  is  developed  in  other  parts ;  but  there 
is  scarcely  any  condition  of  simple  enteritis  and  muco  enteritis  from 
which  patients,  especially  infants,  may  not  recover. 

A  more  favorable  prognosis  may  be  given  when  the  pain  in  the 
abdomen  subsides,  when  the  bowels  act  naturally,  and  the  evacua- 
tions are  of  a  healthy  character:  when  the  tongue  is  uninjected,  the 
skin  supple  and  generally  perspiring,  the  pulse  quiet,  the  countenance 
cheerful,  and  when  there  has  been  refreshing  sleep. 

Treatment. — We  believe,  then,  in  the  existence,  in  these  cases,  of 
an  inflamed  condition  of  the  mucous  membrane,  which  may,  or  does 
already  extend,  to  the  submucous,  muscular,  and  peritoneal  coats ; 
and,  if  we  consider  the  pathological  conditions  of  the  disease,  the 
indications  of  treatment  becomes  evident. 

1.  Allow  the  diseased  part  to  rest. 

2.  Give  the  most  bland  and  unirritating  diet. 

3.  And  avoid  the  use  of  purgatives. 

It  is  exceedingly  unadvisable  to  try  and  produce  action  on  the 
bowels  by  violent  purgative  medicine,  as  by  jalap,  senna,  scamrnony, 
calomel,  blue  pill,  croton  oil,  crude  mercury,  and  the  like.  The 
peristaltic  action  is  checked  by  the  inflamed  state  of  the  coats  of  the 
intestine,  and  additional  irritation  retards  it  still  further.  Leeches 
applied  to  the  abdomen,  or  depletion  from  the  arm,  has,  in  some  in- 
stances, been  followed  by  free  evacuation  from  the  bowels,  and  by 
the  relief  of  pain,  but  we  should  not  recommend  the  resort  in  these 
cases  to  the  latter  remedy.  Warm  fomentations  should  be  applied 
to  the  abdomen. 

When  irritating  ingesta  are  retained,  producing  and  perpetuating 
the  disease,  we  may  administer,  at  an  early  period,  a  purge  of  calomel 
or  gray  powder,  followed  by  castor  oil,  or  linseed  oil  with  opium,  or 
a  free  saline  purge,  as  the  potassio-tartrate  of  soda,  or  sulphate  of 
magnesia. 


MUCO-ENTERITIS    AND    ENTERITIS.  287 

"When,  however,  there  is  tenderness,  it  is  more  safe  to  give  calo- 
mel, or  gray  powder,  combined  with  opium,  several  times  during  the 
day ;  but  it  is  well  to  avoid  the  continued  use  of  mercurials. 

Alkalies  are  of  service,  in  acting  as  sedatives  to  the  mucous  mem- 
brane, in  diminishing  its  engorged  state,  and  in  neutralizing  irritat- 
ing secretions,  as  the  bicarbonate  of  potash,  in  doses  of  gr.  x,  or  gr. 
xv,  and  the  solution  of  potash  in  doses  of  "Lxv  to  xx,  properly  di- 
luted. Chlorate  of  potash,  in  gr.  v  to  gr.  x,  and  carbonate  of  soda, 
gr.  v  to  gr.  xv,  combined  with  narcotic  remedies,  as  hyoscyamus  and 
conium,  are  in  other  instances  apparently  beneficial.  The  latter 
remedies  appear  to  act  on  the  involuntary  muscular  coat,  and  on  the 
nerve  supply  of  the  intestine.  A  valuable  combination  in  less  severe 
cases  is  gray  powder  with  Dover's  powder. 

Some  administer  rnagnesian  salines,  as  sulphate  of  magnesia  and 
calcined  magnesia ;  but,  where  there  is  a  tendency  to  extension  of 
the  disease  to  the  peritoneal  coat,  I  think  sulphate  of  magnesia  is  in- 
jurious, in  increasing  the  peristaltic  action  of  the  intestines,  although 
in  its  direct  effect  on  the  inflamed  membrane,  it  may  lead  to  'the 
emptying  of  the  capillaries  by  watery  evacuation. 

Best  in  bed  is  important,  that  the  intestines  may  not  be  disturbed 
in  their  position,  since  perforation,  in  many  cases,  follows  ulceration 
of  the  intestine ;  and,  there  may  be  also  extension  of  peritonitis  from 
inattention  to  this  simple  rule.  There  must  also  be  abstinence  from 
irritating  food ;  in  fact,  nothing  but  the  most  mild  and  bland  ingesta 
should  be  taken ;  demulcent  drinks,  milk  alone,  or  united  with  lime- 
water  or  soda-water,  as  the  case  may  be,  will  be  grateful  to  the 
patient.  Great  care  is  necessary  after  the  subsidence  of  the  more 
active  symptoms,  in  the  return  to  nourishing  and  substantial  food, 
as  Avell  as  in  the  use  of  any  active  exertion.  The  warmth  of  the 
abdomen  should  be  maintained,  if  there  be  pain,  by  the  use  of  warm 
poultices ;  and  in  all  cases  the  abdomen  should  be  well  surrounded 
with  flannel. 

In  children  with  muco-enteritis,  chlorate  of  potash  is  a  valuable 
remedy,  and  in  some  cases,  it  appears  to  act  with  as  much  benefit  as 
in  cases  of  stomatitis.  Citrate  or  bicarbonate  of  potash  are  also  of 
real  service.  In  other  cases,  when  the  motions  are  clayey  and  white, 
minute  doses  of  calomel  are  sometimes  administered,  with  carbonate 
of  soda,  or  chalk,  as  the  compound  soda  powder  of  the  Guy's  Phar- 
macopoeia; but  much  injury  is  often  done  by  calomel  and  gray  powder 
in  these  cases,  and  in  numerous  instances  we  have  found  their  use 
unnecessary ;  astringents  may  be  given,  as  chalk,  with  catechu,  or 
krameria,  or  logwood,  with  small  doses  of  opium  ;  but  in  very  young 
infants  it  is  better  altogether  to  avoid  the  use  of  opium,  if  possible. 

Maunsell  and  Evanson  mention  the  value  of  dilute  nitric  acid 
with  minute  doses  of  opium  and  simaruba,  and  I  have  often  used 
this  combination  with  advantage.  Ipecacuanha  is  a  valuable  remedy 
where  there  is  no  irritability  of  the  stomach,  and  it  may  be  com- 
bined with  chalk  medicine  or  with  alkalies.  It  has  also  been  recom- 
mended as  an  injection.1 

1  Boudon  and  Chouppe,  'Bulletin  Genfirale  de  Tlierapeutique,'  1874. 


288  MOOD-ENTERITIS    AND    ENTERITIS. 

In  children,  also,  it  is  essential  only  to  administer  food  that  can  be 
easily  digested,  and  although  it  may  appear  of  a  proper  kind,  if  the 
symptoms  continue,  a  change  should  be  made.  The  disease  often 
comes  on  at  weaning ;  and  the  greatest  care  is  required  in  seeking 
for  a  suitable  diet  at  that  period;  "tops  and  bottoms,"  with  water, 
and  with  or  without  a  small  quantity  of  milk ;  dried  flour,  biscuit 
powder,  &c.,  may  be  given,  or  milk  and  water  alone.  I  have  seen 
cases  where  the  only  food  that  could  be  borne  was  water  boiled  for 
a  considerable  time  with  rice,  and  after  partaking  of  this  fluid  the 
vomiting  and  purging  ceased,  and  a  gradual  return  to  more  substantial 
food  was  attained.  For  some  infants,  it  may  be  necessary  to  obtain 
a  wet  nurse,  but  this  is  a  measure  to  be  avoided  if  possible.  Asses' 
milk  is  the  best  substitute  for  the  natural  supply  ;  and  a  small  quan- 
tity of  cream,  with  water,  can  sometimes  be  taken  when  simple  milk 
cannot  be  borne.  Swiss  milk  and  Liebig's  malt  extract  are  sometimes 
very  useful,  and  sometimes  raw  meat  may  be  used  as  subsequently 
described. 

The  prostration  in  children  is  sometimes  so  great  that  stimulants 
are  necessary.  The  aromatic  spirit  of  ammonia  may  be  given  with 
infusion  of  cusparia,  and  with  astringents:  but  in  many  instances  I 
have  seen  life  apparently  saved  by  the  timely  use  of  brandy,  or  wine, 
administered  very  frequently  and  in  small  doses ;  thus  to  a  child 
aged  three,  almost  in  a  dying  state,  the  pulse  scarcely  perceptible, 
the  extremities  cold,  the  eyes  half  closed,  brandy  in  doses  of  fifteen 
drops,  diluted  with  water  or  demulcents,  was  given  every  quarter  of 
an  hour,  and  in  a  few  days  the  child  was  really  convalescent.  In 
other  cases,  white  wine  whey  produces  a  similar  beneficial  result ; 
but  the  use  of  alcoholic  stimulants  in  young  children  requires  great 
care  and  caution ;  they  are  often  the  cause  of  enteric  inflammation, 
and  I  have  in  some  instances  known  the  exhaustion  increased  by 
their  use,  for  the  irritant  effect  due  to  their  administration  prevented 
the  digestion  of  proper  food. 


289 


CHAPTER    IX. 

STRUMOUS  AND  TUBERCULAR  DISEASE  OF  THE  ALIMENTARY  CANAL. 
LARDACEOUS  DISEASE. 

INFLAMMATORY  disease  of  the  alimentary  canal  in  strumous  sub- 
jects can  scarcely  be  separated  from  the  more  slow  and  insidious 
strumous  disease,  which  has  less  active  symptoms  and  seerns  to  origi- 
nate spontaneously.  Struma  should  not  be  looked  upon  as  a  disease 
of  isolated  organs  of  the  body ;  but  as  one  in  which  the  power  of 
assimilation  is  diminished,  the  nutritive  functions  are  imperfectly 
performed,  and  the  cellular  elements  of  the  tissues  unnaturally  prone 
to  degeneration.  Disease  set  up  by  the  ordinary  exciting  causes  in 
subjects  of  this  kind  leads  to  the  various  forms  of  strumous  deposit 
and  its  subsequent  changes.  A  blow  on  an  epiphysis  leads  to  stru- 
mous disease  of  the  bone;  a  slight  bronchitis  to  strumous  pneumonia, 
and  the  formation  of  tubercular  substance  in  the  lungs;  over-excite- 
ment of  the  brain  to  hydrocephalus  and  strumous  meningitis;  slight 
irritation  of  the  mucous  membrane  of  the  intestine,  or  muco-enteritis, 
to  caseous  changes  in  the  rnesenteric  glands,  of  the  mucous  mem- 
brane, and  submucous  tissues.  The  antecedent  abnormal  conditions 
are,  I  believe,  common  to  these  changes  and  to  tuberculosis;  damp 
air,  a  want  of  light  and  proper  food,  imperfect  rest,  hereditary  dis- 
position, and,  perhaps,  syphilitic  taint,  induce  the  imperfect  elabora- 
tion of  those  products  necessary  for  healthy  growth  and  nutrition; 
and  in  this  state  the  blood,  the  nervous  force,  the  vital  activity  of 
every  part  of  the  body,  are  unable  to  return  to  the  normal  type  on 
the  slightest  derangement,  and  strumous  inflammation  and  degene- 
ration take  place. 

The  strumous  and  tubercular  diatheses  are  closely  allied,  and  may 
clinically  be  regarded  as  varieties  of  the  same  morbid  condition. 
The  tendency  towards  the  preponderance  of  the  changes  character- 
istic of  the  one  or  the  other  will  vary  in  different  individuals.  In 
one  person,  the  tubercular  form  is  so  strongly  marked  that  without 
any  appreciable  exciting  cause,  general  tuberculosis  will  spread 
throughout  the  tissues;  in  another,  a  chronic  disease  of  similar  form 
is  manifested;  some  will  be  affected  by  acute  forms  of  strumous 
pneumonia,  whilst  in  others  chronic  processes  of  caseation  gradually 
extend  over  a  greater  or  less  extent  of  the  lymphatic  system;  but 
all  these  varieties  have  intermediate  states,  and  show  their  mutual 
affinities  by  combining  in  many  patients  their  several  pathological 
appearances.  These  remarks  are  especially  applicable  in  treating  of 
tubercular  or  strumous  disease  of  the  abdominal  cavity;  for  on  the 
one  hand,  we  shall  have  to  speak  of  tubercular  peritonitis,  a  disease 
which  may  be  so  distinctive,  that  it  has  been  proposed  to  separate  it 
19 


290  STRUMOUS    DISEASE    OF 

from  other  tubercular  affections,  and  give  it  a  separate  name  j1  on 
the  other  hand,  we  shall  find  what  is  apparently  the  same  disease 
mixed  up  with  caseous  changes,  particularly  in  association  with  in- 
testinal ulceration  and  diseases  of  the  Fallopian  tubes,  and  we  shall 
also  have  to  describe  a  caseous  degeneration  of  the  mesentric  glands 
without  any  miliary  tubercle  whatever. 

Strumous  and  tubercular  disease  of  the  alimentary  canal  are  ob- 
served under  various  forms : — 

1.  Severe  diarrhoea  as  it  occurs  in  children  of  strurnous  diathesis, 
without  amyloid  or  other  disease  of  the  mesenteric  glands  or  intestine. 

2.  Primary  disease  of  the  mesenteric  glands — tabes  mesenterica. 

3.  Tubercle  in  the  peritoneum,  and  strumous  peritonitis  in  its 
several  forms. 

4.  Tubercle  in  the  mucous  membrane  with  enteritis,  leading  to 
softening,  ulceration,  and  perforation,  as  is  frequently  observed  in 
phthisis. 

5.  Tubercle  in  the  appendix  caeci. 

1.  Diarrhoea  in  strumous  children. — The  symptoms  are  very  similar 
to  those  which  we  have  described  as  present  in  gastro-enterite,  but 
here,  being  engrafted  upon  a  strumous  constitution,  they  are  more 
easily  induced,  and  are  less  yielding  to  medicinal  treatment.     This 
disease  causes  the  death  of  thousands  of  infants  among  the  poor  of 
London,  nor  does  it  spare  the  rich,  when  there  is  hereditary  predis- 
position.    The  diarrhcea  is  frequently  set  up  by  some  change  in  the 
diet  or  by  other  improper  nourishment ;  by  disordered  secretion  from 
the  stomach,  intestines,  or  liver;  and  it  often  follows  the  exhaustion 
of  measles  or  scarlet  fever.     Many  of  these  cases  are  cured  by  the 
removal  of  the  exciting  causes,  and  by  the  administration  of  simple, 
corrective  medicines.     When,  however,  these  causes  cannot  be  re- 
moved ;  when  the  infant  cannot  be  taken  from  offensive  exhalations, 
and  from  a  damp  or  cold  atmosphere  ;  when  no  food  can  be  adminis- 
tered or  when  there  is  a  very  feeble  and  strumous  constitution,  too 
frequently  does  the  diarrhoea  continue ;  the  little  patient  becomes 
wasted,  the  countenance  is  expressive  of  extreme  distress,  and  has 
an  aged,  care-worn  appearance;  the  evacuations  consist  of  greenish 
thin  mucus,  of  food  only  partially  changed,  or  they  resemble  the 
washings  of  meat,  and  are  exceedingly  offensive.     The  skin  is  dry, 
sallow,  and  wrinkled  ;  the  abdomen  is  full,  sometimes  hot  and  tender, 
and  there  is  pain  of  paroxysmal  character;  the  mouth  is  dry,  and 
sometimes  aphthous,  the  tongue  is  slightly  furred,  the  breath  is  offen- 
sive, the  eyes  languid  and  the  sleep  is  often  disturbed  with  starting 
moans.    Sometimes  the  stomach  is  irritable,  or  the  appetite  is  craving, 
and  the  child  distressed  by  thirst.     Such  are  the  symptoms  of  severe 
gastro-enterite  rendered  intractable  by  strumous  deposit,  and  passing 
into  the  condition  described  as  tabes  mesenterica. 

In  some  cases  even  of  extreme  exhaustion,  the  little  patient  rallies 
when  proper  remedial  means  can  be  employed ;  in  others  the  diar- 

1  Granulia.     See  Dr.  Bastian,  "Discussion  on  Tubercle,"  'Path.  Soc.  Trans.,'  vol. 
xxv,  p.  330. 


THE    ALIMENTARY    CANAL.  291 

rhoea  persists  day  after  day,  slightly  abating  and  then  returning  with 
renewed  violence,  till  at  last  the  infant  dies  exhausted,  or  convulsions 
come  on  before  the  close  of  life.  It  rarely  happens  that  with  very 
severe  diarrhoea  there  is  much  cough,  although  the  lungs  may  be 
throughout  filled  with  miliary  tubercles. 

Post-mortem  appearance. — After  death  we  may  find  no  apparent 
change  in  the  whole  tract  of  the  mucous  membrane ;  the  liver, 
spleen,  and  lungs  may  be  normal ;  the  mesenteric  glands  may  be 
enlarged  and  swollen,  and  in  some  instances  they  contain  evidence  of 
degeneration  at  their  central  parts.  It  might  be  questioned,  whether 
a  disordered  mucous  membrane  did  riot  induce  this  condition  of  the 
glands ;  but  whether  so  produced  or  primary  in  its  origin,  there  can 
be  little  doubt  that  it  leads  to  the  maintenance  of  an  abnormal  state 
of  the  mucous  canal,  and  indicates  strumous  cachexia.  When  .we 
have  a  more  vigorous  constitution,  one  free  from  struma  or  imperfect 
nutritive  power,  the  patient  often  rallies,  and  the  fatal  symptoms  are 
checked. 

Treatment. — In  the  treatment  of  these  cases,  it  is  most  important 
to  remove  all  exciting  causes  of  disease,  and  every  impediment  to 
the  healthy  performance  of  nutrition  and  growth  ;  to  inculcate  per- 
fect cleanliness,  and  the  inhalation  of  pure  air ;  to  administer  the 
most  mild  and  unirritating  food,  and  to  afford  warmth  to  the  body. 

The  child  should  have  warm  baths ;  be  clothed  in  flannel ;  and  the 
air  of  the  room  must  be  maintained  at  an  equable  temperature.  Milk 
will  not  agree  with  some  infants,  in  whatever  form  it  may  be  given ; 
others  will  retain  asses'  milk,  or  milk  with  lime-water  or  .soda- water, 
when  pure  milk  is  constantly  rejected.  In  some  cases  the  condensed 
milk  properly  diluted  is  kept  down  ;  and  in  others,  again,  only 
artificial  foods  can  be  taken;  the  best  of  these  are,  water  boiled  for 
a  long  time  Avith  rice  ;  "tops  and  bottoms,"  gently  simmered  with 
water  and  without  sugar ;  dried  flour ;  biscuit-powder ;  and,  as  a 
dernier  ressort,  a  wet-nurse  must  be  obtained. 

Another  very  useful  food  is  raw  meat,  first  recommended  by  Dr. 
Weisse,  of  St.  Petersburgh.  A  piece  of  lean  steak  is  procured,  and, 
after  grating  it,  it  is  to  be  beaten  into  a  pulp ;  then  mixed  with  a 
little  sugar,  and  a  teaspoonful  may  be  given  three  or  four  times  a 
day.  Should  the  child  refuse  it  in  this  form,  it  may  be  stirred  into 
very  thin  chicken  or  mutton  broth  scarcely  warm. 

While  advocating  the  occasional  necessity  of  artificial  food,  it  is  to 
be  remembered,  that  for  young  children  it  is  only  to  be  used  to  coax 
the  stomach  into  a  quiet  state,  and  that  as  soon  as  possible  a  gradual 
return  to  some  form  of  milk  diet  is  to  be  attempted. 

In  the  medicinal  treatment,  where  chalk  mixture  made  with  dill 
or  cinnamon  water,  and  with  or  without  a  few  drops  of  ipecacuanha, 
does  not  avail,  I  have  found  great  benefit  from  the  administration  of 
the  compound  logwood  mixture  of  the  Guy's  Pharmacopoeia : 

Misturse  Cretae,  fluidunc.  vj  ; 
Extract!  Haematoxyli,  dr.  j  ; 
Vini  Ipecacuanhas,  fluidr.  j  ; 
Vim  Opii,  fluidr.  ss. 


292  STRUMOUS    DISEASE    OF 

This  in  doses  of  one  or  two  teaspoonfuls,  or,  the  compound  infusion 
of  catechu,  with  a  small  quantity  of  opium,  and,  if  need  be,  a  few 
drops  of  aromatic  spirit  of  ammonia,  is  very  useful.  The  krameria 
is  also  a  valuable  astringent,  with  or  without  chalk  and  opium,  as 
in  the  following  Guy's  preparation: — Decoction  of  krameria  Jxv, 
(root  Six,  with  water  Oj,  boiled  to  3xv).  Ipecacuanha  wine  and 
tincture  of  catechu,  of  each  3vj,  and  syrup  Biss.  A  teaspoonful  to  a 
tablespoonful  as  a  dose,  according  to  the  age  of  the  child. 

When  a  strumous  condition  exists,  great  benefit  is  derived  from 
the  administration  of  cod-liver  oil,  with  steel  wine,  or  from  the  latter 
medicine  alone.  If  vomiting  be  absent,  cod-liver  oil  is  sometimes 
exceedingly  serviceable-;  when  it  cannot  be  taken,  dilute  nitric  acid, 
with  infusion  of  cusparia,  and  a  few  minims  of  compound  tincture 
of  camphor,  are  of  benefit,  especially  when  other  means  have  some- 
what moderated  the  diarrhoaa. 

In  some  cases  small  doses  of  sulphate  of  copper,  as  |  to  £  of  a 
grain,  or  of  nitrate  of  silver  in  similar  quantity,  or  of  acetate  of  lead 
in  J  or  1  grain  doses  may  be  prescribed  with  one  or  two  grains  of 
•Dover's  powder.  Mercurials  are,  I  have  generally  found,  detrimen- 
tal, and  continued  doses  of  calomel  greatly  aggravate  the  disease. 
Small  enemata  of  starch  may  be  used  with  benefit,  and  where  we 
have  a  good  nurse,  other  agents  may  be  well  applied  in  this  way ; 
a  weak  solution  of  nitrate  of  silver  or  of  borax  tends  to  diminish  the 
irritation  of  the  lower  bowel,  and  may  prevent  prolapse.  When 
exhaustion  is  extreme,  nourishment  must  be  administered  every  few 
minutes,  if  the  stomach  can  retain  it ;  and  small  quantities  of  wine 
or  brandy,  as  previously  mentioned.  In  not  a  few  cases  alcohol  has 
been  the  means  of  prolonging  life  and  restoring  infants  to  health  who 
were  apparently  in  a  dying  state. 

This  form  of  diarrhoea  is,  however,  not  confined  to  children.  The 
following  case  is  an  instance  of  that  kind,  where  apparently  simple 
diarrhoea  assumed  an  obstinate  type ;  no  form  of  medicine  or  diet 
checked  it  for  many  days,  and  at  last  the  patient  sank.  There  was 
evidence  of  some  inflammatory  action  at  the  lower  part  of  the  ileum ; 
intense  congestion,  slight  diphtheritic  effusion,  and  ulceration  of  the 
Peyer's  glands  were  found ;  but  these  appearances  were  so  local  that 
they  were  not  considered  sufficient  in  themselves  to  explain  the 
severity  of  the  abdominal  symptoms.  There  were  minute  tubercles 
in  the  peritoneum,  and  degenerating  products  in  the  mesenteric  glands 
which  indicated  the  strumous  constitution  of  the  patient.  The  lungs 
contained  neither  vomica  nor  miliary  tubercle,  but  some  iron- gray 
deposit,  and  a  little  cheesy  matter  were  found  at  the  apex,  and  in  the 
lower  lobe  there  was  ordinary  hepatization,  which  had  evidently 
come  on  a  short  time  before  death. 

CASE  XCVIII.  Slight  Strumous  Disease  of  the  Mesenteric  Glands. 
Diarrhcea.  Pneumonia — Charles  A — ,  get.  30,  a  waiter,  was  admitted  into 
Guy's  Hospital,  August  15th,  1855. 

Three  years  previously  he  had  had  severe  diarrhoea  ;  and  five  weeks  before 
admission,  he  had  had  pain  at  the  stomach,  with  vomiting  and  loss  of  appetite. 
He  lost  flesh  considerably  ;  he  was  feverish  and  emaciated.  The  cause  of  the 


THE    ALIMENTARY    CANAL."  293 

diarrhoea  was  not  evident.  The  respiration  was  coarse  at  the  apices  of  the 
lungs,  but  he  had  no  cough.  The  abdomen  was  collapsed,  and  free  from 
pain  ;  no  tumor  nor  abnormal  condition  could  be  detected  on  careful  manipu- 
lation ;  his  tongue  was  moist  and  not  injected,  and  there  was  no  hoarseness. 
His  urine  was  non-albuminous;  sp.  gr.  1014.  Chalk,  kino,  opium,  copper, 
oxide  of  silver,  were  prescribed  ;  the  last  appeared  most  effective  ;  but  although 
the  diarrhoea  ceased  for  a  short  time,  he  did  not  appear  to  derive  nourishment 
from  food ;  an  attack  of  diarrhoea  came  on  a  few  days  before  his  death,  on 
October  21st,  1855.  Inspection  twenty-six  hours  after  death: — The  body 
was  extremely  emaciated,  and  the  eyes  were  sunken.  In  the  chest  there 
were  slight  pleuritic  adhesions  at  the  right  apex  ;  at  the  extreme  apices  there 
was  old  iron-gray  deposit.  No  miliary  tubercles  existed.  The  lower  lobe  of 
the  lung  was  hepatized.  The  larynx  was  healthy.  The  bronchial  glands 
were  normal.  In  the  jejunum  the  mucous  membrane  was  gray,  and  in  the 
ileum,  it  was  intensely  congested ;  one  of  Peyer's  patches,  about  two  feet 
from  the  caecum,  was  ulcerated,  and  the  membrane  in  several  parts  had  a 
thin  adherent  brownish  covering,  as  of  epithelium  stained  by  adherent  feces. 
On  examination  this  was  found  to  consist  of  columnar  epithelium.  The 
caecum  was  intensely  congested,  and  its  membrane  was  ecchymosed.  The 
surface  presented  epithelium,  blood,  and  some  mucus ;  and  the  capillaries 
were  full  of  blood.  The  colon  was  in  a  similar  state,  but  rather  less  intensely 
congested ;  no  ulcer  could  be  found.  The  appendix  caeci  was  full  of  feces. 
The  mesenteric  glands  varied  exceedingly  in  size,  from  that  of  a  pea  to  a 
pigeon's  egg ;  some  were  swollen,  red,  and  oedematous ;  others  contained 
caseous  product ;  and  in  some  parts  beneath  the  peritoneum  of  the  mesentery 
were  minute  tubercles.  A  minute  examination  of  the  abdominal  viscera, 
nerves,  and  vessels,  failed  to  show  any  other  disease. 

This  case  was  believed  to  be  one  of  phthisis,  in  which  there  was 
extensive  ulceration  of  the  colon;  but  this  was  not  found  after  death; 
disease  of  the  mesenteric  glands  appeared  to  have  been  the  original 
malady ;  and  this  was  the  explanation  of  the  gradual  emaciation. 
The  diarrhoea  was  the  result  of  subacute  disease  of  the  mucous  mem- 
brane, and  of  ulceration  of  the  ileum,  but  it  was  increased  by  the 
great  congestion  of  the  mucous  membrane  of  both  small  and  large 
intestines.  This  was  the  most  marked  symptom,  and  tended  more 
than  any  other  to  exhaust  the  patient.  The  ordinary  remedies  were 
unavailing ;  but  of  these,  the  oxide  of  silver,  with  conium,  appeared 
to  be  the  most  effective.  An  attack  of  acute  pneumonia  was  the 
immediate  precursor  of  a  fatal  termination. 

2.  In  disease  of  the  mesenteric  glands — tabes  mesenterica — the  cel- 
lular constituents  of  the  glands  themselves  undergo  multiplication, 
and  subsequently  degenerating,  the  structure  of  the  glands  becomes 
destroyed.  Extensive  disease  of  this  character  necessarily  prevents 
the  absorption  of  chyle  into  the  system.  The  glands  show  the  dis- 
ease in  various  stages  and  gradations ;  in  some  there  is  but  scanty 
abnormal  product,  in  others  the  whole  gland  is  destroyed  and  very 
much  enlarged,  constituting  a  whitish  mass,  the  size  of  a  pigeon's  or 
hen's  egg.  The  disease  consists  of  glandular  and  fatty  matter,  and  of 
imperfectly  developed  cells ;  and  the  swollen  and  injected  state  of 
less  diseased  glands  appears  to  indicate  that  inflammation  or  hyper- 
aemia  is  associated  with  the  morbid  change. 


294  STRUMOUS    DISEASE    OF 

The  pathological  process  appears  in  its  outset  to  be  essentially  of 
an  inflammatory  or  irritative  character.  The  glands  or  lymphatic 
tissue  become  hyperaemic  and  fleshy,  their  cellular  elements  multi- 
ply, and  crowding  upon  each  other  and  upon  the  stroma  in  which 
they  lie  they  cut  off'  their  own  blood  supply  and  speedily  degenerate. 
While  the' cells  in  the  central  parts  are  degenerating  into  fatty 
material,  those  at  the  circumference  are  gradually  infiltrating  the 
surrounding  unaffected  parts  and  increasing  the  size  of  each  nodule. 
These  changes  closely  resemble  those  which  take  place  in  a  single 
tubercle.  The  disease  continues  to  increase,  the  cells  dying  in  the 
centre,  but  growing  at  the  circumference,  till  large  masses  of  caseous 
material  are  formed :  if  the  process  be  very  chronic  the  outlying 
cells  may  be  seen  to  form  fibrous  tissue  so  as  to  encapsule  the  dis- 
ease ;  and  it  would  appear  that  by  the  formation  of  this  envelope 
the  increase  of  the  growth  is  arrested,  and  the  disease  becomes  qui- 
escent. Then  it  is  that  the  last  stage  is  reached,  namely,  that  of 
calcareous  change  in  the  caseous  cells.  The  spread  of  tubercle  thus 
traced  applies  to  all  parts,  whether  it  be  in  glands  or  in  minute  spots 
of  tissue  in  the  lymphatic  spaces  of  a  serous  or  mucous  membrane, 
and  whether  it  occur  in  the  brain,  the  lung,  the  serous  surfaces,  or 
elsewhere. 

Whilst  these  changes  are  going  on  in  the  glands  the  lacteals  be- 
tween them  become  enlarged  and  distended  with  similar  material, 
and  we  can  trace  the  distended  ducts  to  the  intestine,  where  they 
ramify  on  its  surface.  At  this  part  we  generally  find  a  cluster  of 
tubercles  and  ulceration  of  the  mucous  membrane ;  and  were  it  not 
that  the  glands  appear  to  be  in  a  state  of  more  advanced  disease  than 
the  intestine,  we  should  suppose  that  the  ulceration  of  the  mucosa 
was  followed  by  absorption  and  then  by  glandular  disease.  The 
peritoneum  is  sometimes  studded  with  miliary  tubercles,  or  we 
merely  find  minute  clusters  opposite  points  of  ulcerated  intestine. 
Inflammatory  products  are  also  found  in  the  serous  membrane  in 
various  degrees,  either  constituting  bands  of  adhesion,  or  uniting 
the  intestine  in  one  mass.  (See  Strumous  Disease  of  the  Peri- 
toneum.) 

Symptoms. — Diarrhoea,  as  we  have  previously  mentioned,  is  one 
of  the  symptoms  of  mesenteric  disease.  There  is  gradual  wasting, 
from  the  obstruction  of  the  chyle  vessels,  and  from  the  cessation  of 
the  supply  naturally  poured  into  the  thoracic  duct.  The  patient 
has  an  anxious  expression  of  countenance ;  there  is  dryness  of  the 
skin ;  injection  of  the  tongue,  which  is  more  or  less  furred,  and  a 
craving  appetite ;  the  desire  for  food  being  insatiable.  The  bowels 
are  irregular,  for  though  often  loose,  they  may  be  sometimes  consti- 
pated. There  are  occasional  attacks  of  severe  pain,  and  the  evacua- 
tions have  sometimes  been  found  to  contain  a  large  quantity  of  fatty 
matter. 

The  marasmus  gradually  becomes  extreme,  and,  whilst  the  limbs 
are  wasted,  the  abdomen  is  considerably  enlarged,  and  protuberant. 
The  abdomen  is  full  and  rounded,  but  it  rarely  happens  that  the 
enlarged  glands  can  be  felt  on  tactile  examination ;  we  more  easily 


THE    ALIMENTARY    CANAL.  295 

discover  them  in  the  neck  and  in  the  axillae.  Where  peritonitis, 
and  ulceration  of  the  intestines  have  baen  produced,  pain  is  a  more 
common  symptom. 

A  fatal  termination  may  result  from  diarrhoea,  or  other  organs 
become  implicated,  as  the  brain  and  lungs,  causing  death  by  tuber- 
cular  bronchitis,  by  convulsion,  or  hydrocephalus.  In  other  in- 
stances disease  in  the  epiphyses  of  the  bones  takes  place,  but  the 
patients  in  these  cases  present  less  advanced  disease  of  the  glands  of 
the  mesentery. 

A  fatal  result  does  not  necessarily  follow  this  condition  of  the 
chylopoietic  glands  unless  the  disease  be  very  extensive ;  we  have 
evidence  of  this  fact  in  the  calcareous  condition  in  which  the  glands 
are  found  when  death  has  followed  from  other  causes,  as  from 
phthisis,  or  from  tubercular  meningitis ;  but  the  interference  with 
the  elaboration  of  chyle  increases  the  tendency  to  the  formation  of 
strumous  products  in  other  parts. 

At  the  period  when  this  less  severe  disease  existed,  and  the  sub- 
sidence of  which  had  left  the  calcareous  state  just  mentioned,  gastro- 
euterite  had  probably  occurred  ;  or,  without  any  febrile  excitement, 
the  child  had  been  observed  to  be  imperfectly  nourished,  its  growth 
retarded,  and  its  nutritive  power  evidently  feeble.  It  is  in  this  early 
stage  of  the  disease  that  proper  attention  to  the  health  of  the  child 
may  correct  commencing  degenerative  changes,  which  will,  if  fully 
developed,  necessarily  prove  fatal.  Too  frequently,  however,  the 
physician  is  consulted  when  the  opportunity  for  checking  morbid 
action  has  passed  by. 

Diagnosis. — In  its  earliest  condition  strumous  disease  of  the  me- 
senteric  glands  may  easily  be  mistaken  for  simple  diarrhoea,  or  gas- 
tro-enterite ;  and  what  is  of  greater  importance,  the  sympathetic 
affection  of  the  brain  sometimes  renders  it  exceedingly  difficult  to 
distinguish  between  strumous  disease  of  the  abdomen  and  tubercular 
meningitis.  In  the  former  there  may  be  cerebral  oppression,  grind- 
ing of  the  teeth  in  sleep,  smarting,  occasional  vomiting,  and  convul- 
sion ;  but  in  the  latter  the  mind  is  generally  less  active,  there  is 
strabismus,  or  an  evident  abnormal  condition  of  the  pupils ;  the  ab- 
domen is  collapsed  rather  than  distended;  there  is  greater  unwilling- 
ness for  exposure  of  the  skin  to  cold  air,  the  bed-clothes  are  drawn 
firmly  down  when  the  patient  is  sensible;  and  again,  the  superficial 
capillary  circulation  is  more  disturbed,  and  the  vessels  yield  easily 
to  distension.  It  is  in  this  way  that  the  so-called  "  tache  cerebrale" 
is  produced.  On  drawing  the  finger  across  the  skin,  a  deep  line  of 
congestion  appears  and  remains  for  a  short  time;  this  indication, 
however,  is  by  no  means  constant  or  certain.  In  the  cerebral  disease 
vomiting  is  often  a  marked  symptom,  especially  at  an  early  stage ; 
and  this  with  irregularity  of  the  pulse  are  the  two  symptoms  which 
are  most  reliable. 

In  the  cachexia  produced  by  enlarged  spleen,  by  miasmatic  disease, 
by  lardaceous  disease  of  the  liver,  or  of  other  glands,  by  disordered 
viscera  associated  with  worms,  symptoms  arise  which  in  some  re- 


296  STRUMOUS    DISEASE    OF 

spects  simulate  mesenteric  disease.  The  history  of  the  case,  and  the 
presence  of  enlargem?nt  of  the  liver  or  spleen,  assist  our  diagnosis. 

In  children  affected  by  any  of  the  various  kinds  of  intestinal 
•worms,  the  symptoms  are  pallor,  irregular  bowels,  wasting,  distended 
abdomen,  and  voracious  appetite ;  but  there  is  often  present  more 
irritation  about  the  nose  and  anus  than  in  mesenteric  disease;  there 
is  less  emaciation,  and  the  disease  is  more  amenable  to  treatment. 

Tubercular  peritonitis  is  frequently  associated  with  mesenteric 
disease,  and  is  with  great  difficulty  distinguished  from  it.  The  ab- 
dornen  is  less  supple  when  the  peritoneum  is  implicated,  and  when  the 
disease  is  advancsd  the  intestines  move  en  masse;  there  are  tenderness 
and  distension,  the  pain  is  more  severe ;  but  the  emaciation  is  less 
manifest.  Ulceration  of  the  small  or  large  intestine  and  diarrhoea 
may  be  present  in  either  disease,  but  very  many  of  the  cases  usually 
designated  tabes  mesenterica  are  really  tubercular  peritonitis. 

In  strurnous  subjects,  however,  after  gastro-enterite,  or  slight  peri- 
tonitis, the  intestines  sometimes  become  much  distended  with  flatus, 
and  these  cases  at  first  sight  resemble  ascites ;  a  very  unfavorable 
prognosis  may  be  given,  whilst  with  rest,  good  air,  cod-liver  oil  and 
steel,  and  occasional  alteratives,  the  health  becomes  established,  and 
the  distension  and  pain  disappear.  The  insidious  character  of  stru- 
mous  peritonitis  must  be  well  remembered  ;  pain  may  be  entirely  ab- 
sent, and  the  emaciation  steadily  progressive. 

The  prognosis  in  well-marked  cases  of  mesenteric  disease  must  be 
exceedingly  unfavorable ;  for  when  there  is  any  general  affection  of 
the  glands  the  obstruction  to  the  introduction  of  food  into  the  system 
is  scarcely  less  complete  than  in  direct  pressure  on  the  thoracic  duct. 
Numerous  inspections  after  death,  however,  show  us  that  there  may 
be  degeneration  of  many  of  these  glands.  Some  become  calcareous 
and  pass  evidently  into  a  passive  state,  whilst  others  of  them  are  re- 
stored to  their  normal  condition,  and  life  may  thus  be  prolonged  for 
many  years,  till  strumous  disease  in  some  other  form,  or  another 
malady,  proves  fatal.  Such  cases  also  occasionally  terminate  fatally 
from  intestinal  obstruction  many  years  after  they  have  been  appa- 
rently cured.  The  inflammatory  deposit  causes  contraction  or  leads 
to  bending  of  the  intestine  upon  itself  at  an  acute  angle. 

The  age  of  infancy  is  most  liable  to  mesenteric  disease,  but  it  is 
frequent  at  any  period  from  the  first  to  the  completion  of  the  second 
dentition;  in  those  who  attain  to  early  manhood  it  is  much  more 
frequently  found  associated  with  strumous  peritonitis  and  with 
phthisis. 

The  causes  of  this  disease  have  been  previously  mentioned ;  they 
are  hereditary  predisposition,  improper  food,  and'the  substitution  of 
artificial  foods  for  the  mother's  milk,  insufficient  rest,  the  want  of 
cleanliness  and  light,  the  exanthems,  as  measles,  scarlet  fever,  and 
smallpox,  exposure  to  cold,  and  to  a  damp,  humid  atmosphere,  prob- 
ably also  congenital  syphilis.  Each  of  these  causes  diminishes  the 
nutritive  energy  of  the  system,  and  a  slight  exciting  cause  then 
becomes  sufficient  to  set  up  the  disease;  and  when  it  is  developed 


THE    ALIMENTARY    CANAL.  297 

to  accelerate  it,  so  that  it  becomes  quickly  manifest  in  a  marked 
degree. 

Simple  mesenteric  disease  is,  however,  rare,  even  in  strumous 
subjects ;  for  we  generally  find  that  there  is  also  tubercular  disease 
of  the  peritoneum  or  of  the  mucous  membrane ;  and  in  many  cases 
of  tubercular  peritonitis,  and  of  phthisis  with  ulcerated  intestine,  the 
glands  are  unaffected. 

Treatment. — It  must  always  be  remembered,  that  in  this  disease 
waste  advances  and  increases,  whilst  the  supply  of  reparative  material 
to  the  blood  is  cut  off. 

Our  chief  aim,  therefore,  must  be  to  facilitate  and  assist  nutrition; 
whatever  is  given  must  be  easy  of  absorption  and  assimilation,  as  we 
have  stated  in  speaking  of  the  diarrhoea  of  strumous  children.  Wine 
may  be  often  taken  with  advantage,  for  alcoholic  liquors  probably 
prevent  waste  going  on  with  such  great  rapidity ;  and  it  has  been 
shown  by  the  observations  of  Dr.  Anstie,  and  of  others,  that  during 
the  administration  of  alcohol  the  excretion  of  urea  is  checked,  and 
the  function  of  other  organs,  especially  that  of  the  lungs,  is  diminished. 

If  there  be  febrile  excitement,  salines,  as  the  bicarbonate  of  potash, 
or  the  citrate  of  ammonia,  in  doses  of  a  few  grains,  may  be  adminis- 
tered ;  and  when  great  restlessness  exists,  gr.  j  or  ij  of  Dover's 
powder,  or  niiij  or  v  of  the  solution  of  hydrochlorate  of  morphia,  are 
of  service.  Mercurials  are  better  avoided;  but  when  the  motions  are 
clayey  and  pale,  and  the  bowels  constipated,  their  use,  in  the  form 
of  gray  powder,  or  calomel  with  bicarbonate  of  soda,  is  occasionally 
beneficial.  A  change  to  sea  air  is  very  desirable  in  the  early  stages 
of  mesenteric  disease.  With  cod-liver  oil  we  may  with  advantage 
combine  iodide  of  potassium,  iodide  of  iron,  &c.  The  preparations 
of  iron,  however,  cannot  in  many  cases  be  taken:  pain  in  the  bowels 
is  produced ;  but  this  is  less  likely  to  follow  the  use  of  steel  wine, 
and  the  saccharine  carbonate  of  iron,  than  the  stronger  compounds. 
Iodide  of  potassium  with  solution  of  potash,  with  very  minute  doses 
of  opium  if  necessary,  continued  for  a  lengthened  period,  are  some- 
times of  considerable  service. 

As  to  external  remedies,  the  tincture  of  iodine  may  be  painted 
over  the  abdomen,  or  slips  of  the  ammoniacum  plaster  with  mercury 
may  be  applied;  but  the  maintenance  of  an  equable  and  warm  state 
of  the  skin  is  of  greater  importance  than  external  medicinal  applica- 
tion. 

3.  Tubercles  in  the  peritoneum  and  strumous  peritonitis.  The  state 
of  the  peritoneum  is  so  closely  associated  with  that  of  the  alimentary 
canal,  that  a  consideration  of  strumous  disease  affecting  that  part 
renders  some  notice  of  the  diseased  peritoneum  necessary. 

Tubercular  peritonitis  is  manifested  in  several  conditions. 

1.  As  miliary  tubercles  covering  the  general  surface  of  the  perito- 
neum— visceral,  parietal,  and  mesenteric,  and  in  some  instances 
associated  with  ascites.  In  some  of  these  cases  of  ascites  there  may 
be  very  little  proof  of  tubercular  growth ;  but  tubercle  may  be  sub- 
sequently developed  as  the  result  of  chronic  irritation  in  patients 
constitutionally  predisposed  to  it. 


298  STRUMOUS    DISEASE    OF 

2.  Caseous  thickening  of  the  peritoneum  and  subperitoneal  connec- 
tive tissue  by  tubercular  growth  which  rapidly  degenerates.  This 
form  is  associated  with  deposit  in  the  glands,  and  with  inflammation 
leading  to  matting  together  of  the  intestines;  sometimes  to  perfora- 
tion from  without,  and  to  the  formation  of  small  fecal  abscesses  and 
sometimes  to  tympanitis  in  a  marked  degree. 

The  presence  of  miliary  tubercles  on  the  peritoneum  is  found  in 
many  cases  of  phthisis,  where  there  is  ulceration  of  the  intestine,  the 
corresponding  surface  of  the  peritoneum  being  covered  with  minute 
tubercles,  and  this  condition  of  local  tuberculosis  may  cause  an  affec- 
tion of  the  whole  peritoneum. 

In  children  who  have  died  from  hydrocephalus,  with  miliary '' 
tubercles  in  the  pia  mater,  or  from  acute  pneumonia  with  miliary 
tubercles  studding  the  whole  of  the  lung,  the  peritoneum  is  frequently 
found  affected  in  the  manner  described,  but  the  disease  of  the  serous 
membrane  does  not  assume  a  condition  of  clinical  or  pathological 
importance. 

The  formation  is  generally  seen  as  semi-transparent  grains,  and 
appears  to  be  situated  both  on  the  surface  and  in  the  deeper  layer  of 
the  peritoneum ;  it  consists  of  an  almost  amorphous  blastema  with 
minute  granules,  and  of  imperfectly  developed  cells,  which  rapidly 
caseate  in  the  centre ;  but  sometimes  around  the  deposit  elongated 
fibre  cells  and  branching  cells  are  observed,  and  there  is  in  all  cases 
of  general  tuberculosis  a  great  amount  of  inflammatory  growth  and 
lyrnph  product. 

In  some  cases  of  peritonitis,  thin  layers  of  lymph  are  deposited  on 
the  peritoneum,  and  the  surface  assumes  a  minutely  granular  appear- 
ance, almost  as  if  sprinkled  with  sand ;  the  grains  thus  produced 
must  not  be  mistaken  for  true  miliary  tubercles ;  they  can  occasion- 
ally be  scraped  off',  and  they  leave  the  serous  membrane  smooth 
beneath,  but  this  cannot  always  be  effected.  The  movement  of  one 
part  of  the  intestine  on  another,  and  the  gradual  deposition  of  lymph, 
appear  to  produce  this  condition.  Sometimes  there  is  a  great  amount 
of  serous  exudation,  and  ascites  is  produced,  whilst  another  more 
severe  form  of  disease  is  that  in  which,  with  strumous  deposit,  there 
is  ordinary  inflammatory  change ;  the  intestines  become  matted  to- 
gether by  lymph,  and  by  low  organized  product,  which  rapidly  un- 
dergoes degeneration,  constituting  cheesy  masses.  These  masses  are 
formed  between  the  coils  of  intestine,  in  the  omentum,  and  in  the 
adhesions  themselves ;  so  that  we  find  the  peritoneal  tunic  of  the 
liver,  spleen,  &c.,  considerably  thickened — three  to  five  lines,  or  more 
— and  in  the  fibrous  tissue  constituting  the  firmer  part  of  the  deposit 
are  tubercles  or  strumous  infiltration.  The  stomach  rarely,  if  ever, 
presents  tubercles  or  tubercular  ulceration  on  its  mucous  surface, 
but  it  is  not  uncommon  to  find  tubercles  on  its  peritoneal  surface. 
The  mesentery  and  its  glands  are  also  generally  found  in  a  similar 
condition. 

The  product  thus  formed  leads  to  union  of  the  intestine,  one  part 
with  another,  so  that  the  peritoneal  cavity  becomes  entirely  obliter- 
ated ;  fresh  deposition  takes  place  as  the  disease  advances,  and  the 


THE    ALIMENTARY  CANAL.  299 

tendency  to  degenerate  increases.  The  masses  soften  down,  the  peri- 
toneal and  muscular  coats  ulcerate,  and  this  process  continues  till 
the  mucous  surface  gives  way,  and  an  opening  is  formed  into  the 
intestinal  canal.  The  perforation  takes  place  from  without,  begin- 
ning at  the  peritoneal  surface.  This  perforation  does  not,  however, 
lead  to  more  extensive  peritonitis ;  the  firm  adhesions  which  have 
already  taken  place  have  obliterated  the  peritoneal  cavity,  and  thus 
prevent  effusion.  Thus,  either  no  extravasation  follows,  or  a  very 
small  fecal  abscess  is  the  result.  The  extension  of  ulceration 
amongst  contiguous  coils  of  intestine  sometimes  leads  to  several  por- 
tions becoming  completely  truncated  and  opening  into  a  fecal  abscess 
in  which  six  or  eight  communications  may  exist.  I  have  examined 
several  cases  in  which  there  were  from  twelve  to  fifteen  communica- 
tions between  portions  of  the  intestine  in  different  parts,  but  without 
fecal  abscess.  In  these  cases  it  is  quite  impossible  to  unravel  the 
intestine,  or  even  to  distinguish  the  various  parts  in  many  instances. 
The  intestine  becomes,  indeed,  a  sac  of  many  pouches  rather  than  a 
continuous  tube.  Should  the  adhesions  be  less  extensive,  perfora- 
tion will  produce  more  marked  symptoms,  if  a  fatal  result  does  not 
very  quickly  follow.  It  is  generally  the  small  intestine  which  is 
found  perforated ;  but  it  may  open  into  the  colon ;  and  once  I  ob- 
served the  jejunum  communicating  with  the  transverse  colon.  In 
a  recent  case,  a  child,  aged  three  years,  after  measles  had  tympan- 
itic  distension  of  the  abdomen  with  diarrhoea ;  perforation  took  place 
into  the  bladder;  feces  were  passed  by  the  penis,  and  urine  was  ap- 
parently discharged  by  the  rectum.  There  was  no  pain,  but  the 
child  sank  in  a  few  days. 

It  is  more  rare  in  strumous  than  in  cancerous  disease  of  the  abdo- 
men and  intestines,  to  find  fecal  abscesses  followed  by  perforation  of 
the  abdominal  parietes.  In  strurna  the  disease  is  often  very  general, 
and  several  fecal  abscesses  exist ;  but  the  adhesions  and  secondary 
perforation  allow  the  contents  of  the  canal  to  be  passed  onwards ;  in 
cancer  the  ulceration  is  more  localized  in  character,  and  gradually 
extends  through  all  the  contiguous  structures.  We  have  seen,  how- 
ever, in  a  child  aged  six,  strumous  disease  of  the  abdomen  followed 
by  perforation  of  the  parietes.  The  effusion  in  some  instances  is  of 
an  ascitic  character,  and  dropsy  is  the  result.  The  peritoneum  is 
thickened,  clear  serum  is  effused,  and  with  it  more  or  less  strumous 
product.  This  is  not  a  rare  disease  among  children,  but  it  is  of  a 
slow,  insidious  character,  and  very  intractable.  It  sometimes  exists 
with  a  lardaceous  condition  of  the  liver  or  of  the  spleen,  but  this  is 
not  always  the  case,  nor  is  it  always  preceded  by  one  of  the  exan- 
thems. 

In  some  instances  of  strumous  peritonitis  the  intestine  appears  to 
lose  its  contractile  power,  and  yields  to  distension,  so  that  most  dis- 
tressing tympanitis  takes  place,  or  there  is  simple  distension  without 
pain,  the  muscular  fibre  having  simply  lost  its  power  of  contraction. 
The  coats  of  the  intestine  become  so  much  softened  that  after  death, 
they  readily  separate  the  one  from  the  other,  and  may  be  torn. in 


300  STRTJMOUS    DISEASE    OF 

long  shreds.  Dr.  Hodgkin  placed  in  the  museum  at  Guy's  several 
^specimens  showing  this  condition  in  a  remarkable  degree.1 

The  symptoms  of  this  form  of  disease  are  also  sometimes  obscure 
at  the  commencement ;  with  a  well-marked  strumous  diathesis  we 
have  pain  in  the  abdomen  of  a  severe  character,  resembling  colic ; 
and  it  is  accompanied  with  considerable  tenderness ;  diarrhoea  and 
febrile  excitement  come  on,  with  injected,  slightly  furred  tongue  and 
with  a  distressed  expression  of  the  countenance.  There  is  a  circum- 
scribed flush  on  one  cheek.  Under  suitable  treatment  and  precaution 
the  active  symptoms  subside,  and  the  patient  feels  relieved  ;  in  a  few 
days  or  weeks,  however,  the  pain  returns,  and  there  is  renewed 
aggravation  of  the  symptoms  and  of  the  febrile  state  ;  it  may  be  that 
a  defined  mass  is  felt  in  the  abdomen,  in  the  umbilical,  hypogastric 
or  iliac  regions ;  the  tumor  is  tender  on  pressure,  and  imperfectly 
resonant  on  percussion. 

These  attacks  are  repeated  from  time  to  time,  and  the  diarrhoea 
becomes  severe,  and  occasionally  is  accompanied  by  vomiting.  The 
body  wastes,  but  the  abdomen  is  large,  and  in  most  cases  it  loses  its 
suppleness,  and  moves  en  masse.  The  tongue  becomes  more  in- 
jected, oftentimes  red  and  morbidly  clean.  The  strength  of  the 
patient  is  broken,  severe  hectic  is  set  up,  attacks  of  pain  are  more 
frequent,  and  portions  of  the  abdomen  become  exquisitely  tender,  at 
length  the  exhaustion  becomes  extreme,  or  more  general  tuberculosis 
is  set  up ;  the  brain  may  be  affected  with  tubercular  meningitis,  and 
coma  or  convulsions  come  on  before  death. 

The  symptoms  somewhat  resemble  those  of  mesenteric  disease  ; 
the  abdomen  is  hot,  often  distended,  and  tympanitic ;  the  recti  are 
rigid ;  the  body  wastes,  the  countenance  becomes  anxious,  and  the 
eyes  sunken ;  the  patient  is  fretful  and  irritable ;  the  bowels  often 
act  with  irregularity ;  the  pain  is  sometimes  a  marked  symptom, 
but  it  is  often  absent,  or  it  merely  resembles  occasional  colic.  The 
wasting  of  the  body  is,  however,  less  than  in  severe  disease  of  the 
mesenteric  glands. 

The  second  form  is  that  in  which  there  is  less  serous  effusion,  but 
the  strumous  product  is  accompanied  by  greater  inflammation,  lymph 
is  effused,  and  the  intestines  are  matted  together  by  bands  of  adhe- 
sion, or  there  is  cough  from  strumous  disease  of  the  lungs ;  but  this 
aggravation  of  the  suffering  is  generally  absent,  for  the  pulmonary 
disease  remains  latent.  The  severe  attacks  of  pain  often  indicate 
the  formation  of  fecal  abscess  or  fresh  accession  of  inflammation  ;  but 
we  shall  dwell  hereafter  on  the  sudden  peritonitis,  which  is  some- 
times set  up  in  subjects  affected  with  csecal  disease  and  phthisis. 

The  symptoms  may  be  exceedingly  insidious  in  those  cases  in 
which  there  is  serous  effusion  into  the  peritoneal  cavity.  The 
patient  becomes  an;emic  and  emaciated,  pain  is  occasionally  paroxys- 
mal, or  less  severe  but  continued.  After  a  time  the  abdomen  becomes 
enlarged  and  the  fluctuation  is  perceived ;  but  there  may  be  neither 
febrile  symptoms  nor  pain,  nor  any  evidence  of  enlargement  of  the 

'  Hodgkin,  'On  Mucous  and  Serous  Membranes.' 


THE    ALIMENTARY    CANAL.  301 

liver  or  spleen,  nor  disease  of  other  viscera.  Strumous  disease  of 
other  organs,  however,  generally  follows,  and  leads  to  fatal  results. 
There  is  great  difficulty  in  producing  absorption  of  this  peritonitic 
fluid;  for  the  peritoneum  is  in  a  passive  condition,  and  medicines 
which  act  on  the  excretory  organs,  as  diuretics,  solution  of  potash, 
or  iodide  of  potassium,  often  fail  in  the  desired  effect ;  and  mercurials 
tend  in  many  instances  to  increase  the  effusion. 

Causes. — Children  in  their  first  dentition,  and  at  the  age  of  puberty, 
in  whom  the  rapid  developmental  changes  are  perverted  by  struma, 
are  very  prone  to.  this  disease,  but  early  manhood  from  15  to  25,  or 
30,  is  by  no  means  exempt ;  and  we  sometimes  observe  it  at  much 
later  periods  of  life,  even  in  patients  of  50  to  60  years  of  age. 

The  predisposing  causes  are  those  of  strumous  disease  generally — 
hereditary  taint,  unwholesome  food,  the  want  of  cleanliness,  a  damp 
humid  state  of  atmosphere,  exposure  to  cold,  insufficient  light,  &c. 
Light  is  as  essential  to  healthy  growth  as  cleanliness ;  but  unfortu- 
nately the  absence  of  the  one  often  entails  the  loss  of  the  other.  The 
dark  offensive  dwellings  of  poverty  present  terrible  manifestations 
of  some  of  the  sources  of  struma ;  but  it  is  also  to  be  found  amongst 
the  rich  in  whom  hereditary  tendency,  exposure  to  cold,  &c.,  are 
sufficient,  with  very  slight  exciting  causes,  to  induce  these  affections. 

The  hyperaernic  state  of  the  ovaries  at  commencing  menstruation 
sometimes  suffices  to  determine  the  deposition  of  strumous  product, 
and  to  cause  strumous  peritonitis  extending  from  the  pelvic  viscera ; 
this  is  especially  the  case  when  menstruation  in  young  subjects  has 
been  checked  by  exposure  to  cold. 

Peritoneal  disease  of  this  form  is  sometimes  excited  by  blows  or 
falls  on  the  abdomen,  or  it  follows  diarrhoea  from  injudicious  food 
or  excess ;  we  observe  it  also  as  a  sequel  to  typhoid  fever  ;  the  follic- 
ular  ulceration  of  the  intestine  and  irritation  of  the  mesenteric  glands 
being  followed  by  strumous  disease. 

The  diagnosis  has  already  been  spoken  of  in  mesenteric  affections; 
we  may  further  add,  that  when  strumous  disease  of  the  abdomen  is 
associated  with  like  disease  of  the  brain,  the  symptoms  are  often 
more  than  usually  obscure;  cerebral  symptoms,  such  as  delirium 
and  coma,  may  be  followed  by  prostration,  distension  of  the  abdo- 
men, and  vomiting  ;  and  the  general  aspect  of  the  disease  may  closely 
resemble  enteric  fever. 

The  prognosis  in  well-marked  cases  is  very  unfavorable ;  but  at 
an  early  stage,  before  the  disease  has  become  pronounced,  much  may 
be  done  to  render  the  changes  which  have  occurred  passive,  and  to 
prevent  the  accession  of  fresh  disease. 

Treatment.— The  indications  for  treatment  are  very  similar  to  those 
mentioned  in  mesenteric  disease.  As  far  as  possible  the  exciting 
cause  of  the  disease  should  be  taken  away ;  and  although  this  is 
less  practicable,  we  must  attempt  the  removal  of  the  condition  which 
constitutes  the  disease.  This  may  in  part  be  effected  by  sea  air,  by 
iodine,  cod-liver  oil,  iodide  of  potassium,  and  the  milder  preparations 
of  steel.  Nourishment  should  be  freely  given,  and  of  a  character 


302  STRUMOUS    DISEASE    OF 

that  can  be  easily  assimilated.  Improper  food  may  induce  most 
severe  colic,  and  defeat  all  remedial  measures. 

The  inflammatory  state  is  best  counteracted  by  the  application  of 
leeches  and  counter-irritants;  as  cantharides,  or  iodine,  applied  ex- 
ternallv;  in  children,  it  is  well  to  place  a  portion  of  tissue  paper 
betwee'n  the  cantharides  and  the  skin,  and  only  to  apply  the  plaster 
for  two  or  three  hours ;  or  to  use  for  a  short  time  the  acetum  ean- 
tharidis ;  or  still  better,  the  Cantharidine  Blistering  Tissue. 

When  fluid  exists,  diuretics  may  be  tried,  but  they  are  not  of 
much  service.  Great  care  is  required  in  allowing  exercise,  because 
at  the  same  time  that  fresh  air  and  change  are  exceedingly  desirable 
to  improve  the  health,  rest  is  most  important  for  the  abdominal 
organs  themselves.  Slight  movements  may  break  down  adhesions, 
and  lead  to  rapid  extension  of  disease,  and  to  a  fatal  termination. 
The  importance  of  rest  to  the  viscera  of  the  abdomen  can  scarcely 
be  urged  with  sufficient  force. 

Again,  it  is  most  desirable,  that  mercurial  medicines  and  drastic 
purges  should  be  avoided ;  the  gentlest  laxatives  and  mild  enemata 
are  all  that  are  required. 

Various  symptoms  arise  which  demand  almost  daily  attention,  as 
diarrhoea  or  occasional  vomiting,  each  of  which  must  be  checked  by 
appropriate  treatment.  In  a  case  of  strumous  peritonitis  recorded 
by  Dr.  Hughes  in  the  'Guy's  Reports'  of  1856,  creasote  was  pre- 
scribed to  check  severe  vomiting ;  it  produced  urine  almost  of  the 
color  of  indigo,  but  it  relieved  the  patient.  Pain  must  be  moderated 
by  opium  in  small  doses,  or  by  morphia ;  by  warm  fomentations  or 
cataplasms ;  by  chloroform. ;  or  by  belladonna  applied  to  the  pari- 
etes. 

Gentle  pressure  by  a  bandage,  and  the  irritation  of  the  ammonia- 
cum  with  mercury  plaster,  are  sometimes  of  service;  and  in  those 
cases  in  which  fluid  is  poured  out,  tapping  is  sometimes  advisable; 
for  in  chronic  peritonitis  the  serous  membrane  often  forms  a  thick- 
ened, and  almost  a  passive  sac. 

CASE  XCIX.  Strumous  Peritonitis.  Fecal  Abscess.  Artificial  Anns. — 
A  little  girl,  set.  6,  had  been  suffering  from  chronic  peritonitis  for  about  a 
year.  The  abdomen  became  much  distended,  and  there  was  severe  vomiting, 
with  great  emaciation.  Six  months  before  death  a  circumscribed  tumor 
formed  near  the  umbilicus  ;  this  afterwards  broke,  and  discharged  feces. 

On  inspection,  the  lungs  were  found  studded  with  tubercles  ;  the  intestines 
were  adherent,  and  several  portions  were  perforated ;  they  had  formed  a 
fecal  abscess  near  the  umbilicus,  which  had  discharged  externally.  The 
Fallopian  tubes  were  filled  with  soft  strumous  product.  (Prep,  in  Guy's 
Museum,  244G50.) 

4.  Disease  of  intestine  in  phthisis  pulmonalis. — The  mucous  mem- 
brane of  the  intestine  is  frequently  the  seat  of  tubercle  ;  and  although 
tubercles  are  rarely,  if  ever,  found  in  the  mucous  membrane  prima- 
rily, they  are  often  associated  with  strumous  disease  of  the  lung,  of 
the  serous  membrane,  of  the  brain,  or  of  the  bones. 

A  very  common  position  for  this  deposit  is  in  the  substance  of  the 


TUB    ALIMENTARY    CANAL.  303 

mucous  membrane,  at  the  lower  part  of  the  ileum,  and  generally  in 
the  aggregate  or  solitary  glands.  The  deposition  takes  place,  as  in 
the  lungs,  without  any  evidence  of  inflammatory  disease,  and  the 
tubercles  are  found  as  minute  grains,  one  sixteenth  to  one  eighth  of 
an  inch  in  diameter,  and  of  an  opaque,  cheesy  appearance.  On  ex- 
amination they  will  be  found  to  consist,  in  most  instances,  of  an  im- 
mense number  of  granules  of  fat,  with  imperfect  nuclei,  though  if 
they  are  found  in  their  earliest  stages  they  consist  of  the  same  kind 
of  growth  as  we  have  previously  described;  in  other  instances  the 
centre  is  semi-fluid,  softened  down ;  still  more  advanced,  we  find  that 
the  slight  covering  of  the  mucous  membrane  has  given  way,  and  a 
small  ulcer  is  formed,  with  a  depression  in  its  centre,  and  with  an 
irregular  and  slightly  excavated  margin.  This  formation  is  proba- 
bly in  most  cases  preceded  by  hypersemia  of  the  mucous  membrane 
or  by  inflammatory  action;  and  although  it  appears  nearly  established 
that  inflammatory  action  is  not  essential  to  its  deposition,  this  state 
tends  to  accelerate  degeneration,  and  the  repeated  deposition  of  stra- 
in ous  product  at  the  margin  of  the  ulcer.  When  inflammatory 
action  has  taken  place,  the  edge  of  the  ulcer  is  found  to  be  injected 
and  irregular,  and  to  have  extended  rapidly ;  in  some  cases,  also, 
sloughing  has  taken  place.  The  extent  of  this  diseased  state  varies 
exceedingly ;  generally  only  the  lower  part  of  the  ileum  is  affected,  and 
next  in  frequency  the  rest  of  the  ileum  and  the  caecum.  With  these 
parts,  the  colon  is  sometimes  diseased  in  its  whole  length;  and  lastly, 
also,  the  other  portions  of  the  small  intestines,  the  jejunum,  and  even 
the  duodenum. 

We  frequently  find,  that,  at  the  base  of  the  ulcer,  immediately 
beneath  the  peritoneum,  there  are  numerous  minute  tubercles,  appa- 
rently caused  by  a  direct  process  of  spreading  to  adjoining  parts  of 
infection.  In  other  instances  the  mucous  membrane  is  raised,  and 
presents  a  small  swelling,  about  a  quarter  of  an  inch  in  elevation, 
and  a  quarter  to  half  an  inch  in  diameter ;  and  on  making  a  section 
of  this  minute  tumor,  a  collection  of  pus  is  found  in  it;  a  sort  of 
small  abscess  in  the  mucous  membrane.  (/See  Cases  on  Disease  of 
the  Caecum.) 

But  strumous  ulceration  of  the  intestine,  when  associated  with 
phthisis,  sometimes  manifests  itself  differently.  There  is  scarcely 
any  diarrhoea,  but  sudden  intense  pain  is  followed  by  collapse,  and 
too  often  by  fatal  peritonitis.  A  minute  ulcer  has  increased  in  depth 
so  as  to  extend  through  the  muscular  coat,  and  then  through  the 
peritoneum.  It  may  be  that  this  peritonitis  is  localized,  or  that  a 
fecal  abscess  is  formed,  and  of  these  several  accidents  we  shall  have 
to  speak  more  fully.  The  affections  of  the  appendix  caeci  will  also 
require  a  fuller  notice. 

In  other  instances  the  diseased  intestine  is  found  to  be  in  a  healing 
condition,  while  the  affection  of  the  lungs  has  steadily  progressed,  or 
having  become  rapidly  aggravated,  has  led  to  a  fatal  result.  I  have 
several  times  seen  cicatrices  in  the  intestine  in  phthisis,  when  there 
was  no  evidence  to  show  previous  disease  of  a  different  kind,  as 
typhoid  fever.  In  one  instance,  admitted  into  Guy's  Hospital  several 


304  STRUMOUS    DISEASE    OF 

years  ago,  there  were  symptoms  of  intestinal,  and  it  was  feared  in- 
superable, obstruction;  but  the  patient  was  spared  to  linger  on  for 
many  weeks,  and  died  from  phthisis  pulmonalis.  A  cicatrix  was 
found  in  the  ileum,  leading  to  very  considerable  contraction  of  the 
intestine,  and  no  doubt  it  had  been  the  cause  of  the  previous  symp- 
toms of  obstruction. 

In  some  patients  in  whom  the  jejunum  and  ileum  have  been  ulce- 
rated throughout,  with  less  affection  of  the  colon,  the  diarrhoea  has 
been  exceedingly  severe.  When  the  mesenteric  glands  are  also  af- 
fected, we  have  several  times  observed,  extending  from  an  ulcer  in 
the  jejunum  or  ileum,  distended  lacteals,  reaching  to  the  infiltrated 
glands,  and  filled  with  yellow  cheesy  product.  Some  regard  the 
ulceration  of  the  intestine  as  the  cause  of  the  disease  in  the  lacteals 
and  glands ;  others  consider  that  the  gland  was  primarily  diseased, 
and  that  the  obstructed  lacteals  and  local  congestion  consequent  upon 
it  have  set  up  the  ulceration  at  that  part  of  the  intestine.  Simple 
distension  of  the  lacteals  is  more  common  in  cancerous  disease,  from 
pressure  on  the  thoracic  duct;  whilst  in  struma  abnormal  product 
fills  and  enlarges  the  lacteals. 

In  many  cases  of  phthisis  the  intestine  appears  to  have  taken  part 
in  the  general  atrophy  of  the  whole  body,  and  we  find  the  coats  of 
the  intestine  much  thinned,  of  a  pale  color,  and  even  semi-transparent. 
Again,  the  mucous  membrane  sometimes  does  not  present  any  lesion, 
although  the  patient  may  have  had  severe  diarrhoea,  and  this  with- 
out any  evidence  of  lardaceous  disease. 

The  extent  and  severity  of  the  affection  of  the  intestine  are  very 
diverse.  In  cases  where  the  phthisis  is  of  a  pneumonic  character, 
when  there  is  extensive  effusion  into  the  lung  tissue,  rapid  disor- 
ganization, considerable  fever,  and  speedy  termination,  the  intestines 
are  sometimes  unaffected.  It  is  in  more  chronic  cases  that  we  gene- 
rally find  this  condition  most  marked. 

In  one  hundred  cases  of  phthisis  in  only  thirteen  were  the  intestines 
found  to  be  healthy,  and  those  were  cases  of  the  character  just  men- 
tioned, namely,  pneumonic  phthisis.  In  sixty-nine  cases  the  ileum 
was  diseased,  and  generally  the  colon  also,  in  a  greater  or  less  degree ; 
in  seventeen  cases  the  colon  only  was  diseased.  The  ileum  is  the 
part  most  frequently  affected.  In  more  severe  cases,  the  colon  is 
also  diseased,  sometimes  in  its  whole  length,  or  merely  at  the  sigmoid 
flexure ;  or  we  find  the  whole  alimentary  tract  diseased,  and  the 
jejunum,  ileum,  and  colon  are  all  ulcerated  and  inflamed. 

Attacks  of  diarrhoea  generally  alternate  with  constipation  in 
phthisical  disease  of  the  intestine,  and  thin  bilious  evacuations  are 
occasionally  mixed  with  blood.  The  discharge  from  the  bowels  is 
sometimes  composed  of  mucus  passed  in  long  strings  or  casts,  or  it 
presents  the  character  of  yeast;  in  a  case  of  this  kind  under  my  care, 
the  evacuation  closely  resembled  the  matters  discharged  from  the 
stomach  in  obstructed  pylorus,  but  with  a  fecal  instead  of  a  sour 
odor.  Under  microscopical  examination  minute  cells  and  grains  in 
a  state  of  change  were  observed,  but  not  the  ordinary  torula,  nor  the 
sarcina  ventriculi.  In  other  .instances  the  disease  resembles  acute 


THE    ALIMENTARY    CANAL.  305 

dysentery,  blood  and  mucus  are  passed,  with  considerable  tenesmus ; 
there  is  slight  griping  pain,  but  the  discharge  from  the  bowels  resists 
all.  treatment ;  it  may  be  checked  for  a  few  days,  but  again  returns, 
and  it  is  remarkable  in  some  cases  how  completely  the  thoracic  symp- 
toms are  in  abeyance;  neither  cough,  dyspnoea,  pain,  nor  distress  about 
the  chest  may  trouble  the  patient,  although  after  death  considerable 
vomicse  may  be  detected  in  the  lung.  In  some  of  these  instances  the 
appearances  of  the  colon  are  quite  those  of  a  dysenteric  character, 
the  extent  of  the  ulceration  destroying  in  some  cases  the  mucous  and 
muscular  coats,  leaving  but  small  islets  of  injected  mucous  membrane; 
in  other  instances  the  surface  is  covered  by  diptheritic  membrane, 
and  presents  isolated  patches  of  superficial  ulceration  beneath.  Many 
of  these  appearances  have  been  observed  in  the  numerous  cases  of 
phthisis  which  have  died  at  Guy's  Hospital,  and  it  is  probable  that 
the  more  damp  air  of  the  Borough  of  Southwark,  the  ill  ventilated 
home  in  Bermondsey  and  Kotherhithe,  from  which  some  of  these 
patients  have  come,  have  induced  this  dysenteric  state. 

It  would  appear  that  exposure  to  cold  and  wet  is  sometimes  the 
cause  of  the  unusual  severity  in  the  affection  of  the  alimentary  canal 
in  phthisis.  In  other  cases,  the  administration  of  mercurial  medi- 
cines, of  drastic  purgatives,  and  of  improper  food,  induces  this  con- 
dition. 

The  presence  of  fistula  in  ano,  as  a  complication  of  phthisis,  is 
frequent ;  and  it  is  a  question  upon  which  opinions  are  varied,  whether 
the  division  of  the  sphincter  is  advisable  in  such  cases.  Most  sur- 
geons would  dissuade  from  the  operation  at  the  later  stages,  but  in 
the  earlier  condition,  before  there  is  any  disorganization  of  the  lung, 
the  removal  of  a  depressing  and  exhausting  discharge  may  tend  to 
re-establish  health,  so  also  when  hemorrhage  takes  place  from  the 
part;  sometimes,  however,  the  pulmonary  symptoms  rapidly  increase 
after  the  operation. 

With  albuminuria  in  strumous  subjects,  disease  of  the  colon  leads 
sometimes  to  severe  diarrhoea  and  great  exhaustion.  The  association 
of  phthisis  with  renal  disease  is  not  of  very  frequent  occurrence ;  in 
these  cases  the  ileum  and  colon,  as  in  ordinary  phthisis,  may  be 
ulcerated,  or  the  rectum  may  be  especially  diseased.  '  The  use  of 
purgatives  to  relieve  anasarca  has  been  followed  in  some  of  these 
cases  by  serous  diarrhoea  of  a  very  intractable  nature ;  inflammation 
and  ulceration  are  set  up,  and,  like  ulceration  on  the  extremities  in 
dropsy,  may  be  the  immediate  cause  of  death. 

Treatment. — The  1st  object  should  be  as  much  as  possible  to  re- 
move the  exciting  causes  of  diarrhoea ;  2d,  to  check  irritating  secre- 
tions by  correctives  and  astringents;  3d,  to  soothe  the  inflamed 
membrane  by  demulcents  and  by  opiates. 

In  most  cases  the  avoidance  of  indigestible  food,  of  uncooked 
fruit,  and  of  malt  liquors,  is  sufficient  to  check  the  purging  in  ordi- 
nary phthisical  disease  of  the  intestine ;  if  not,  an  injection  of  starch 
and"  opium  may  be  used  with  benefit.  Suet  and  milk  is  an  unirrita- 
ting  form  of  nourishment,  and  is  often  of  much  service ;  other  de- 
20 


306  STRUMOUS    DISEASE    OF 

mulcents,  too,  are  used  with  advantage ;  and  when  the  powers  of  the 
patient  are  much  depressed,  port  wine  or  brandy  must  be  prescribed. 

Opium  alone,  or  in  combination,  is  of  great  value,  as  in  Dover's 
powder,  the  compound  kino  powder ;  and  it  may  be  given  with 
acetate  of  lead,  with  sulphate  of  copper,  with  bismuth,  or  with  oxide 
of  silver.  Bismuth  alone  will  oftentimes  quiet  this  irritable  condi- 
tion of  the  alimentary  canal;  alkalies  also,  and  astringents,  as  the 
compound  krameria  mixture  and  the  compound  logwood  mixture  of 
the  Guy's  Pharmacopoeia,  will  often  be  found  valuable  remedial 
agents. 

Although  in  some  cases  cod-liver  oil  acts  on  the  bowels,  in  other 
instances  it  moderates  diarrhoea,  and  the  bowels  act  with  less  violence 
and  pain. 

I  have  found  the  injection  of  borax  with  barley  water,  or  powdered 
charcoal  with  the  same  agent,  of  more  service  in  some  cases  where 
the  colon  is  much  affected,  than  simple  starch  with  .opium.1 

If  there  be  severe  pain  the  application  of  hot  cataplasms  or  of 
mustard  affords  partial  relief. 

It  is  the  exception  to  find  phthisis  free  from  abdominal  complica- 
tion, but  the  following  instances  present  some  peculiarities  in  refer- 
ence to  this  affection :  in  one  case  the  mesenteric  glands  were  very 
extensively  diseased,  and  the  lacteals  distended  with  strumous  pro- 
duct ;  the  diarrhoea  was  exceedingly  obstinate,  and  hastened  the  fatal 
termination.  In  another,  the  pulmonary  symptoms  were  entirely 
masked,  but  there  is  no  doubt  that  the  dysenteric  inflammation  was 
more  intractable  in  character  on  account  of  the  disorganization  of  the 
lungs.  If  there  had  been  no  inspection  after  death,  the  latter  would 
probably  have  been  considered  by  many  practitioners,  who  did  not 
take  the  trouble  carefully  to  examine  the  chest,  as  simple  disease  of 
intestine.  Each  case  of  phthisis  must  be  considered  by  itself;  the 
different  degrees  of  pneumonic  inflammation,  of  laryngeal  disease, 
and  of  glandular  or  abdominal  complication,  &c.,  render  the  secon- 
dary symptoms  exceedingly  modified  and  varied,  whilst  the  broad 
general  characters  bear  very  close  similarity ;  much  relief  may  be 
afforded  by  suiting  the  treatment  to  these  sources  of  discomfort  and 
danger. 

CASE  C.  Strumous  Disease  of  the  Mesenteric  Glands.  Obstruction  of 
the  Lacteals.  Ulceration  of  the  Small  and  Large  Intestine.  Dysentery. 
Phthisis — Willian  S — ,  set.  20,  was  admitted  into  Guy's  Hospital,  August 
29th,  and  died  November  1st,  1855.  With  the  exception  of  a  slight  cough, 
lie  had  enjoyed  good  health  till  the  January  previous  ;  he  then  had  severe 
cold,  and  his  cough  increased  in  severity  ;  he  had  gradually  become  more 
feeble  and  emaciated  till  his  admission.  His  chest  was  narrow  and  con- 
tracted. There  was  dulness  on  percussion  below  the  clavicles ;  and  in  the 
supra-  and  infra-scapular  regions  there  was  also  roughness  jn  the  respiratory 
murmur,  with  bronchial  respiration. 

The  diarrhoea  continued  with  short  intermissions,  and  his  affection  of  the 
throat  increased  ;  he  became  extremely  emaciated,  and  died  November  1st. 

Inspection  twenty-one  hours  after  death.     The  larynx  was  extensively 

1  See  Dr.  Th.  Thompson,  '  On  Consumption.' 


THE    ALIMENTARY    CANAL.  307 

ulcerated.  At  the  apices  of  the  lungs  were  several  vomicse,  and  throughout 
both  lungs  were  numerous  tubercular  deposits  and  miliary  tubercles.  °  The 
bronchial  glands  were  much  enlarged  ;  and  they  were  infiltrated  with  strumous 
product. 

Abdomen — The  intestines  were  tolerably  distended ;  the  peritoneum  pre- 
sented granular  tubercular  deposit,  and  there  was  considerable  injection  of  it 
at  the  parts  of  the  small  intestine  opposite  to  the  ulcerated  portions  of  the 
mucous  membrane :  the  mesenteric  glands  were  very  large  and  prominent, 
of  a  yellowish-white  color,  and  infiltrated  with  low  organized  product ;  some 
of  them  were  the  size  of  a  pigeon's  egg,  and  they  occupied  the  whole  of  the 
mesentery.  In  several  parts  of  the  small  intestine,  lacteals  were  observed  to 
extend  from  the  enlarged  glands  to  the  walls  of  the  intestine ;  these  vessels 
were  white,  irregularly  distended,  and  in  some  places  had  a  moniliform  ap- 
pearance ;  they  extended  in  several  places  upon  the  walls  of  the  intestine,  and 
beneath  the  mucous  membrane  to  ulcers  situated  there.  On  opening  the 
small  intestine,  numerous  ulcers  were  observed ;  they  commenced  in  the 
upper  portion  of  the  jejunum,  and  extended  with  greater  or  less  intervals  to 
the  cajcum  ;  some  were  one  and  a  half  inches  in  length  ;  their  margins  were 
congested,  and  were  irregular  and  undermined  ;  their  surfaces  were  granular, 
as  if  presenting  minute  strumous  deposit.  The  ulcers  were  scattered  about 
six  inches  apart,  and  were  larger  at  the  jejunum  than  in  the  ileum ;  strumous 
tubercles  were  observed  in  many  parts  of  the  ileum  in  the  substance  of  the 
mucous  membrane,  and  there  were  several  minute  ulcers  about  the  size  of  peas. 
The  ileo-caecal  valve  was  much  congested,  and  was  swollen  and  cedematous. 
The  whole  of  the  ca?cum  and  colon  had  a  remarkable  appearance  ;  with  the  ex- 
ception of  a  few  islets  of  raised  congested  membrane,  the  whole  surface,  as  far 
as  the  sigmoid  flexure,  was  destroyed.  The  surface  was  of  a  whitish  granular 
appearance,  presenting  some  congested  points  or  irregular  pits ;  the  section 
showed  that  there  was  low  organized  product  in  the  superficial  layer;  some  true 
tubercles  and  cellular  tissue  dipped  down  into  the  muscular  coat,  and  on  the 
sufrace  itself  there  was  granular  and  imperfectly  formed  cellular  deposit,  like 
diphtheritic  membrane.  The  descending  colon  presented  transverse  irregular 
ulcers,  with  larger  intervening  spaces ;  the  rectum  was  still  less  affected. 
The  appendix  was  much  distended  at  its  superior  two-thirds,  and  was  ulcer- 
ated ;  it  contained  strumous  tubercles.  The  white  substance  in  the  lacteals 
consisted  of  particles  of  fat  irregularly  aggregated  into  numerous  spherical 
masses  ;  and  in  the  mesenteric  glands  there  was  ordinary  strumous  and  im- 
perfectly formed  cellular  growth.  Tiie  liver  was  normal  and  not  fatty ;  the 
spleen  was  healthy. 

CASE  CI.  Ulcerated  Colon.  Phthisis.  No  Cough.— Mich.  M'C —  set. 
53,  was  admitted  with  violent  purging,  which  had  existed  a  week ;  much 
mucus  was  passed  per  rectum,  but  he  had  no  cough.  He  sank  in  a  very 
short  time.  The  whole  of  the  large  intestine  was  intensely  inflamed  and 
ulcerated,  and  the  small  intestines  congested  ;  an  old  vomica  at  the  apex  of 
the  lung  was  surrounded  by  iron-gray  pneumonia. 

The  pulmonary  symptoms  were  masked ;  he  had  no  cough,  but  the  severity 
of  the  abdominal  symptoms,  dysentery  of  an  acute  form,  rapidly  led  to  a  fatal 
result. 

CASE  CII.  Phthisis.  Ulceration  of  the  Rectum  and  Sigmoid  Flexure. 
Hemorrhage  from  the  Bowels.  Ulceration  of  the  Appendix  Ctzci. — A.  B — 
was  admitted  into  Guy's  Hospital,  under  my  care,  March  18th,  1857.  He 


308  STRUMOUS    DISEASE    OF 

was  a  married  man,  of  temperate  habits,  who  had  considered  himself  in  health 
till  one  month  before  admission  ;  his  principal  symptom  had  been  discharge 
of  blood  from  the  rectum  with  diarrhoea  ;  he  had  cough,  had  rapidly  emaci- 
ated, and  he  had  become  completely  blanched.  He  had  evidence  of  phthisis 
at  the  left  apex.  Emaciation  rapidly  increased,  the  cough  became  more 
severe,  and  the  evidence  of  disorganization  of  the  lung  more  decided.  He 
died  in  one  month  ;  and  for  several  days  he  appeared  to  be  in  articulo  mortis. 
On  inspection  there  was  tubercular  affection  of  both  lungs,  and  also  of  the 
larynx.  Small  vomicae  and  red  hepatization  were  found.  The  intestines, 
especially  the  small,  were  empty  and  contracted  ;  and  in  the  lower  part  of 
the  ileum  were  a  few  tubercles  and  commencing  ulceration.  The  transverse 
colon  presented  a  sigmoid  twist  near  the  spleen,  and  the  ascending  and  trans- 
verse colon  contained  some  scybala,  and  presented  several  ulcers,  oval  in 
form,  about  half  an  inch  in  breadth,  with  injected  irregular  margins.  In  the 
sigmoid  flexure  and  rectum,  the  whole  of  the  mucous  membrane  was  injected ; 
it  was  almost  covered  with  patches  of  ulceration,  and  in  some  parts  there 
were  portions  of  adherent  diphtheritic  membrane.  The  appendix  cfeci  was 
twisted  in  a  sigmoid  form ;  and  at  the  right  of  the  caecum,  near  its  terminal 
third,  it  became  very  much  dilated ;  the  mucous  membrane  at  this  part  was 
entirely  destroyed,  and  the  muscular  coat  much  hypertrophied.  The  kidneys, 
liver,  and  spleen  were  healthy. 

The  ulceration  of  the  rectum  and  segmoid  flexure  had  led  to  the 
hemorrhage  which  blanched  the  patient ;  and  in  consequence  of  this 
exhaustion  the  disease  of  the  lung  rapidly  advanced.  It  was  not 
the  part  of  the  intestine  usually  affected  in  phthisis;  and  he  had  no 
pain,  distension  of  the  abdomen,  nor  severe  tenesmus ;  diarrhoea  and 
discharge  of  blood,  were  the  most  marked  symptoms  of  abdominal 
disease.  The  mesenteric  glands  were  more  than  usually  affected. 
The  appendix  ca^ci  was  so  diseased  that  ulceration  would  probably 
have  extended  into  the  peritoneum  or  into  the  cellular  tissue,  if  life 
had  been  prolonged.  The  loss  of  blood  apparently  hastened  the  dis-' 
eased  action  in  the  intestine  rather  than  diminished  it ;  and  although 
the  purging  was  checked,  the  patient  never  appeared  to  rally  to  any 
extent.  He  was  unable  to  take  cod-liver  oil,  but  appeared  partially 
benefited  by  hydrochloric  acid,  with  small  doses  of  opium  and  ca- 
lumba. 

These  instances,  and  many  others  which  might  have  been  adduced, 
show  the  general  constitutional  character  of  phthisical  disease ;  and 
that  although  it  may  manifest  itself  with  greater  severity  in  one 
organ  than  in  another,  we  should  closely  observe  the  state  of  all  the 
viscera,  as  having  a  most  important  influence  on  the  curability  of 
the  disease,  for  these  simultaneous  developments  of  morbid  action 
go  on  very  insidiously,  and  even  when  the  general  state  of  strumous 
disorganization  may  be  past  the  stage  of  reparative  action,  much 
may  be  done  in  partially  relieving  distressing  urgent  complications. 

LARDACEOUS   DISEASE. 

There  are  numerous  conditions  of  the  system  which  manifest 
themselves  in  local  changes ;  those  glandular  diseases  which  we 
have  described  as  the  result  of  a  strumous  or  scrofulous  state  are  the 


THE    ALIMENTARY    CANAL.  309 

result  of  a  constitutional  defect,  and  in  lardaceous  or  amyloid  disease, 
we  have  a  local  affection  especially  of  the  coats  of  the  minute  capil- 
lary arteries  which  though  not  stricly  constitutional,  is  produced  by 
a  general  cause.  This  condition  had  been  recognized  as  a  degenera- 
tive change  many  years  ago,  and  was  believed  to  be  closely  allied  to 
strumous  deposit;  the  bacon-like  appearance  in  the  liver  when 
affected  with  this  disease  had  long  been  known,  hence  the  name 
lardaceous  and  waxy ;  but  it  was  about  1854  that  Yirchow  adopted 
the  term  amyloid  disease  from  the  supposed  identity  of  the  morbid 
product  with  the  vegetable  principle  starch ;  the  laminated  appear- 
ance of  the  corpora  amylacea  observed  in  the  brain,  and  the  color 
produced  by  sulphuric  acid  and  iodine,  led  that  acute  observer  to 
regard  the  blue  matter  produced,  as  identical  with  iodide  of  farina ; 
it  has,  however,  been  subsequently  shown  that  the  iodine  is  itself 
deposited  and  thus  produces  the  blue  discoloration.  Still  there  is  a 
reaction  with  iodine  although  of  a  different  kind  ;  the  affected  tissue 
assumes  with  a  dilute  solution  of  free  iodine  a  deep  brown  color, 
and  it  is  deeply  and  persistently  stained  by  the  blue  of  indigo.  As  to 
the  tissue  affected,  it  is  found  that  the  coats  of  the  minute  capillary 
arterioles  becomes  thickened  by  abnormal  deposit,  at  first  the  mus- 
cular, then  the  other  coats  become  involved,  and  when  colored  by 
iodine  the  vessels  are  very  easily  observed.  These  thickened  vessels 
may  be  seen  in  the  mucous  membrane  of  the  intestine,  in.  the  kidney, 
in  the  Malpighian  tufts,  and  in  the  lymphatic  glands ;  and  in  the 
liver  they  may  be  traced  to  the  circumference  of  the  lobules;  but  it 
is  not  the  capillaries  alone  that  are  affected,  the  cells  of  the  glands, 
especially  of  the  liver,  lose  their  normal  appearance,  they  become 
infiltrated  with  similar  dense  product ;  other  structures  may  be  like- 
wise affected,  the  lymphatic  glands,  the  tonsil,  the  supra-renal  cap- 
sule, the  thyroid,  the  muscles,  the  membranes  of  the  brain,  the  blad- 
der, and  the  serous  membranes  are  all  mentioned  by  my  colleague 
Dr.  Moxon  as  liable  to  this  change.1  As  to  the  nature  of  the  deposit 
it  is  albuminous  in  character,  although,  according  to  Dr.  Marcet,  it 
contains  a  diminished  quantity  of  nitrogen.  Dr.  Dickinson2  states, 
that  it  is  a  fibrinous  matter  with  a  deficiency  of  alkalies,  potash  and 
soda.  "  In  the  healthy  specimens  the  alkaline  salts  varied  between 
89  and  118  parts  in  1000.  With  the  amyloid  the  variation  was  be- 
tween 48  and  107."  He  refers  the  disease  to  a  "  dealkalized  fibrin," 
and  proposes  the  term  "  depurative"  as  indicating  the  nature  of  the 
process.  This  term  is  suggested  by  the  ordinary  cause  of  the  disease, 
for  in  numerous  instances  it  is  found  to  follow  long  continued  suppu- 
ration ;  thus  it  comes  on  after  disease  of  the  bones,  as  necrosis, 
caries,  chronic  abscess,  disease  of  the  spine,  and  suppuration  of  other 
kinds,  as  that  which  is  associated  with  chronic  phthisis,  and  with 
long  continued  ulceration  of  the  intestine,  and  possibly  the  cachexia 
of  tuberculosis  and  struma  may  also  induce  the  disease  ;  but  syphilis 

1  "VVilks  and  Moxon,  '  Pathological  Anatomy,'  p.  641. 

2  "On    Waxy,  Lardaceous,  or    Amyloid   Deposit,"    Dr.    Dickinson,    '  Med.-Chir. 
Trans.,'  vol.  1. 


310 


STRUMOUS    DISEASE    OF 


is  the  second  great  cause  of  lardaceous  disease,  for  nearly  every  case 
is  found  to  be  connected  either  with  syphilis  or  chronic  suppuration. 
It  would  appear  that  unless  the  part  be  extensively  affected,  its  func- 
tional activity  may  be  continued ;  still,  in  later  stages  whether  the 
mucous  membrane  of  the  intestine,  the  liver,  the  spleen  or  the  kid- 
neys be  involved,  the  healthy  action  of  the  part  is  seriously  inter- 
fered with.  It  has  been  shown  by  iny  colleagues,  Dr.  Fagge  and 
Dr.  Goodhart,  that  a  small  amount  of  lardaceous  disease  of  the  vessels 
of  the  kidney  soon  induces  decided  changes  in  the  uriniferous  tubules 
with  proportionate  disturbance  of  the  function  of  the  gland. 

If  the  liver  is  diseased  it  assumes  a  dense,  waxy  appearance  ;  it  is 
heavy,  and  on  a  thin  section  it  appears  semi-transparent  under  the 
microscope;  the  cells  are  found  to  be  dense  and  smaller  than  normal, 
the  nuclei  less  distinct;  and  if  iodine  has  been  used  the  capillaries 
are  observed  to  be  thickened  as  previously  mentioned:  similar 
changes  are  found  in  the  kidney,  &c.  We  have,  however,  especially 
to  do  with  the  mucous  membrane  of  the  stomach  and  intestine ;  the 
stomach  is  less  frequently  involved  than  the  small  intestine ;  the 
mucous  membrane  appears  pale,  thickened,  and  sodden,  and  under 
the  microscope  the  thickened  vessels  are  very  easily  observed. 
Peyer's  patches  are  said  to  be  less  affected  than  the  surrounding 
membrane ;  after  the  arteries,  the  adjoining  tissue  becomes  infiltrated. 

As  to  the  symptoms,  it  is  often  difficult  to  distinguish  those  which 
are  due  to  the  primary  change,  the  chronic  suppuration  and  its  con- 
sequent cachexia,  from  the  true  symptoms  of  lardaceous  disease. 
As  it  is  an  affection  in  which  there  is  a  general  cachexia,  several 
organs  become  affected,  and  we  often  find  both  the  liver  and  the 
kidneys,  the  spleen  and  the  mucous  membrane  of  the  intestine  im- 
plicated at  the  same  time.  The  manner  in  which  one  or  other  of 
these  organs  is  involved,  modifies  the  symptoms. 

The  patient  becomes  pale,  cachectic,  and  if  the  mucous  membrane 
of  the  intestine  be  diseased  a  troublesome  and  persistent  diarrhoea  is 
set  up,  and  hastens  the  fatal  termination;  if  the  kidney  be  affected 
the  albuminuria  and  its  consequent  change  upon  the  condition  of  the 
blood  increases  the  anaemia,  the  exhaustion  is  progressive,-  the  legs 
become  swollen,  the  abdomen  is  often  distended  with  fluid,  the  patient 
generally  remains  conscious,  but  drowsiness  or  convulsions  may  pre- 
cede the  fatal  termination. 

The  prognosis  is  necessarily  very  unfavorable,  and  as  to  treatment 
very  little,  beyond  palliative  measures,  can  be  attempted.  It  is  well 
to  try  and  check  the  diarrhoea  by  stringent  remedies.  The  ordinary 
vegetable  astringents  may  be  given,  as  tannin,  krarneria,  logwood, 
catechu;  so  also  the  mineral  astringents,  as  lead;  afterwards  the 
alkaline  preparations  of  iron  as  the  tartarated  iron. 

Of  150  consecutive  cases  of  lardaceous  disease — 


The  stomach  was  affected 
intestine     . 
liver 

spleen        . 
kidney        .  . 

supra-renal  capsule 
muscle 


9  times. 

63 

73 

99 

110 

S 

1 


THE    ALIMENTARY    CANAL. 


311 


Or  stating  it  in  a  percentage  scale — 


The  stomach  is  affected  in 
intestine 
liver 
spleen 
kidney 

supra-renal  capsule 
muscle 


6     per  cent,  of  all  cases. 

42 

48.7 

66 

73.3 

5.3 

0.6 


This  table  is  probably  a  correct  statement  of  the  average  occur- 
rence of  lardaceous  disease  in  the  various  organs,  except  with  regard 
to  the  stomach.  In  this  viscus  the  affection  occurs  much  more 
frequently  than  the  figures  would  lead  us  to  believe,  but  it  is  not 
examined  specially  in  many  cases,  and  the  lardaceous  change  is 
overlooked.  Still,  it  should  be  stated  that  the  stomach  is  not  so  fre- 
quently affected  as  the  other  viscera,  and  generally  only  when  the 
change  is  extreme  in  them.  It  has,  however,  been  found  to  be 
diseased  when  the  other  organs  were  nearly  healthy. 


312 


CHAPTER    X. 

ON  DISEASES  OF  THE  CAECUM  AND  APPENDIX  (LECI. 

THE  diseases  of  the  csecum  and  of  its  appendix  are  of  so  peculiar 
and  important  a  character,  as  to  call  for  special  consideration. 

To  a  certain  extent,  the  caecum  is  apart  from  the  direct  current  of 
the  contents  of  the  alimentary  canal ;  for  the  valvular  opening  from 
the  ileum  enters  at  two  to  four  inches  from  its  lowest  part,  and  the 
capacity  of  the  sac  is  several  times  greater  than  that  of  an  equal  length 
of  the  ileum.  Hence  also  its  contents  move  more  slowly;  and  at 
the  same  time  they  become  less  fluid  in  their  character.  The  mucous 
membrane  is  here  destitute  of  villi,  but  it  is  exceedingly  vascular, 
and  is  furnished  with  numerous  solitary  glands.  At  this  part  of  the 
intestine  also  the  longitudinal  -muscular  fibres  assume  a  different 
arrangement ;  they  here  form  three  bands,  which  arise  from  the 
position  at  which  the  appendix  is  attached,  and  they  are  continuous 
with  its  muscular  layer.  The  appendix  eaeci  is  an  elongated  glandu- 
lar sac,  which  opens  into  the  intestine  at  the  termination  of  the 
csecum,  and  generally  towards  its  iliac  side. 

The  caecum  is  situated  in  the  right  iliac  fossa,  and  is  only  covered 
by  peritoneum  on  its  anterior  and  lateral  surfaces ;  a  considerable 
quantity  of  loose  tissue  separates  it  from  the  fascia,  and  from  the 
.nerves  and  vessels  in  relation  with  the  psoas  and  iliacus  muscles. 
The  mobility  of  the  caecum  is  therefore  considerably  less  than  that 
of  the  jejunum  or  ileum  ;  but  in  this  respect  there  is  much  variation, 
for  it  is  occasionally  found  with  a  long  mesenteric  attachment,  and 
the  right  iliac  fossa  is  then  completely  covered  by  peritoneum. 

This  freedom  is  far  from  being  of  rare  occurrence ;  it  is  probably 
of  congenital  origin,  and  is  of  great  pathological  importance ;  for  it 
allows  the  caecum  to  pass  into  hernial  sacs,  and  to  change  its  position 
when  there  is  intestinal  obstruction  or  great  distension  from  other 
causes. 

In  reference  to  the  rotatory  movements  of  the  intestine,  Eokitan- 
sky  describes  three  varieties :  first,  rotation  of  the  intestine  upon  its 
own  axis ;  secondly,  upon  the  mesentery  as  an  axis ;  and,  thirdly, 
upon  another  coil  of  intestine.  The  caecum  may  be  regarded  as 
moving  either  on  its  long  or  short  axis.  In  the  former  it  tends  in- 
wards towards  the  spine,  and  the  colon  will  thus  assume  a  direction 
more  or  less  to  the  right,  or  even  a  horizontal  course.  This  con- 
dition we  have  observed  without  any  apparent  impediment  to  the 
passage  of  its  contents ;  but  when  it  is  assoicated  with  habitual  con- 
stipation, there  is  greater  liability  to  distension  of  the  caecum  and 
disease  of  the  appendix.  By  rotation  on  its  long  axis  the  caecum 
may  be  so  twisted,  that  the  ileum  opens  on  the  right  side,  but  when 


ON    DISEASES    OF    CAECUM    AND    APPENDIX    C^CI.  313 

revolving  upon  its  short  axis,  the  appendix  may  be  placed  towards 
the  anterior  abdominal  parietes,  or  it  maybe  situated  at  the  posterior 
aspect  of  the  intestine.  When  these  movements  are  combined  the 
caecum  assumes  various  positions ;  in  one  case  we  noticed  that  the 
appendix  was  directly  towards  the  liver,  and  the  transverse  colon 
was  adherent  to  the  caecum,  forming  a  sigmoid  curve  in  the  centre  of 
the  abdomen.  There  had  not  been  any  evidence  of  obstruction,  but 
if  such  had  occurred,  the  diagnosis  would  have  been  greatly  ob- 
scured. The  ileum  was  in  another  found  to  open  on  the  right,  or 
on  the  posterior  aspect,  but  the  head  of  the  caecum  was  completely 
inverted,  so  as  to  be  directed  towards  the  diaphragm.  In  this  state 
constriction  may  readily  be  produced  as  in  a  case  where  an  inverted 
caecum  became  distended  to  the  utmost,  and  led  to  a  fatal  result. 

In  the  second  form  of  rotation  of  the  caecum,  namely,  upon  the 
mesentery  as  an  axis,  there  seems  to  be  a  still  greater  probability  of 
obstruction.  This  rotation  can  only  take  place  when  the  caecum  is 
very  free,  and  it  may  then  pass  into  the  pelvis,  or  be  completely 
rotated.  We  have  seen  the  caecum  in  the  pelvis,  enormously  dis- 
tended and  ruptured ;  it  was  twisted  upon  its  mesenteric  axis,  and 
the  passage  into  the  colon  obstructed.  In  another  case — one  of  fatal 
obstruction — the  caecum  was  apparently  twisted  on  the  mesentery  as 
well  as  on  its  own  axis.  These  twisted  conditions  of  the  caecum,  and 
the  freedom  of  its  mesenteric  attachment,  are  generally  found  in 
strumous  subjects ;  they  predispose  to  disease  of  this  part  of  the  in- 
testine, and  to  lodgments  in  and  ulceration  of  the  appendix.  We 
have  not,  however,  observed  that  they  have  any  connection  with  an 
abnormal  state  of  the  rest  of  the  intestine. 

The  appendix  presents  characters  still  more  diverse;  but  some  of 
these  appearances  are  the  result  of  pathological  changes,  which  we 
shall  presently  consider.  It  is  generally  three  inches  in  length,  but 
is  sometimes  only  one  and  a  half  inch,  and  at  other  times  it  is  as 
much  as  five  inches.  It  is  attached  on  the  inner  aspect  of  the  caecum 
by  folds  of  peritoneum,  constituting  a  mesentery;  but  whilst  it  is 
generally  free,  it  is  occasionally  hidden  behind  the  caecum,  or  curved 
in  a  sigmoid  form  to  the  right  side. 

The  mesentery  of  the  appendix  is  generally  short,  and  is  some- 
times fixed  to  the  brim  of  the  pelvis,  and  the  appendix  is  then  pen- 
dant in  the  pelvis.  Not  unfrequently  the  mesentery  of  the  appendix 
is  attached  to  the  lower  part  of  the  true  or  iliac  -mesentery;  in  such 
a  case  the  appendix  runs  parallel  with  the  ileum  for  an  inch  or  an 
inch  and  a  half,  and  is  then,  beyond  its  mesentery,  free.  The  direc- 
tion thus  assumed  is  parallel  to  that  of  the  brim  of  the  pelvis  towards 
the  left,  and  the  appendix  nearly  reaches  the  attachment  of  the  sig- 
moid flexure.  When  this  condition  is  present,  we  frequently  have 
a  more  or  less  dependent  pouch  formed  between  the  appendix  and 
the  ileum,  consisting  of  the  folds  of  peritoneum.  This  pouch 
worthy  of  notice,  because  from  irregular  pressure  it  becomes  atro- 
phied," then  probably  perforated,  so  as  to  form  an  opening  through 
which  other  coils  of  small  intestine  may  pass.  The  opening  thus 


314  ON    DISEASES    OF    THE    CAECUM 

formed  oftentimes  becomes  the  cause  of  internal  hernia:  the  traction 
on  the  borders  of  this  opening  being  especially  manifested  in  the 
direction  of  the  attachment  of  the  mesentery  of  the  appendix,  that 
is,  along  the  brim  of  the  pelvis  towards  the  sigmoid  flexure,  leads  to 
fibroid  thickening  in  that  position,  and  as  the  band  becomes  more 
and  more  drawn  forward,  it  assumes  the  appearance  of  an  inflamma- 
tory adhesion.  The  same  traction  may  be  the  predisposing  cause  of 
iilceration  of  the  appendix,  and  we  have  seen  perforation  and  inter- 
nal strangulation  thus  produced,  associated  with  liberation  and  per- 
foration of  the  appendix.  Immediately  above  the  ileum,  at  its  angle 
of  union  with  the  caecum,  we  not  unfrequently  have  another  pouch, 
which  undergoes  similar  changes,  and  may  also  lead  to  strangulation. 

When  the  appendix  cseci  is  fixed  by  abnormal  adhesions,  the 
rotatory  movements  of  the  caecum  to  which  we  have  referred  must 
necessarily  be  modified.  Again,  as  to  the  position  o£  the  csecurn,  we 
may  further  remark,  that  another  congenital  peculiarity  is  sometimes 
found,  namely,  its  presence  in  the  left,  instead  of  the  right  iliac  fossa; 
this  we  observed  in  a  patient  who  died  from  chronic  bronchitis  and 
emphysema,  and  in  whom  the  whole  of  the  abdominal  viscera  were 
laterally  transposed,  the  stomach,  spleen,  and  descending  colon  occu- 
pying the  right  side,  whilst  the  caecum,  the  liver,  and  ascending 
colon  were  found  on  the  left.  The  thoracic  viscera  were  also  trans- 
posed. 

In  a  normal  state  of  parts,  the  ileo-colic  valve  prevents  the  regur- 
gitation  of  fluid  from  the  large  into  the  small  intestines ;  the  greater 
the  distension  of  the  caecum,  the  more  closely  are  the  component 
parts  of  the  valve  compressed,  and  after  death  the  colon  may  be 
fully  distended,  without  escape  of  fluid  into  the  ileum.  Dr.  Brinton 
and  Dr.  Roper  have  shown  that,  if  the  ileum  be  also  over-distended, 
the  valve  ceases  to  act;  there  is  equal  pressure  on  both  sides,  and 
the  contents  of  the  cavities  may  intermingle,  or  pass  from  the  caecum 
into  the  ileum. 

The  secretion  of  the  caecum  is  alkaline  in  its  character.  Tiede- 
mann  and  Grmelin  considered  it  acid,  but  in  many  cases  that  I  have 
examined,  it  has  been  found  alkaline.  Chemical  action  probably 
takes  place  on  particles  of  alimentary  matter  left  unacted  upon  by 
the  gastric  juice,  and  by  the  secretions  poured  into  the  small  intes- 
tine. 

This  action  is  very  much  less  than  that  which  takes  place  in  the 
small  intestine,  and  there  does  not  appear  to  be  sufficient  warrant 
for  the  statement  that  the  caecum  constitutes  a  second  stomach  and 
that  true  digestion  takes  place  there.  It  is  more  probable  that  the 
watery  parts  of  the  chyme,  if  the  semi-fecal  contents  of  the  ileum 
may  be  so  called,  become  absorbed  by  a  very  extensive  capillary 
circulation;  and  that  the  glands  remove  from  the  blood  excremen- 
titious  material  no  longer  of  any  service  to  the  system. 

The  appendix  is  an  elongated  gland  of  a  very  simple  character, 
resembling  the  pancreatic  caeca  of  the  intestine  of  the  fish,  and  as 
far  as  is  at  present  known,  its  secretion  is  of  the  character  of  ordinary 
mucus.  Since  the  feces  here  become  more  solid,  were  it  not  for  such 


AND    APPENDIX    C^ECI.  315 

a  secretion,  assisted  by  that  of  the  ordinary  mucous  follicles,  adhe- 
sion of  feces  would  be  more  likely  to  take  place  with  the  parieties, 
and  thus  cause  distension.  The  secretion  is  poured  out  at  that  part 
which  is  most  likely  to  effect  this  separation,  namely,  at  the  origin  of 
the  triple  muscular  band. 

Pathology. — The  unusual  mobility  of  the  caecum,  which  has  pre- 
viously been  referred  to,  is  of  a  congenital  character,  but  it  may 
induce  serious  pathological  conditions,  as  before  mentioned. 

The  vilh  cease  at  the  ileo-colic  valve,  but  we  sometimes  find  in 
the  caecum  and  ascending  colon  elongated  processes,  resembling  enor- 
mously hypertrophied  villi  scattered  over  the  mucous  membrane. 
In  a  case  which  occurred  at  Guy's,  they  were  nearly  half  an  inch  in 
length,  about  one  line  in  breadth,  and  they  covered  the  caecum  and 
ascending  colon,  but  were  not  known  to  have  produced  any  symp- 
toms, nor  to  have  had  any  influence  on  the  cause  of  death. 

Atrophy. — Since  only  a  part  of  the  caecum  is  covered  by  the  longi- 
tudinal bands,  we  frequently  find  that  in  atrophic  states  of  the  intes- 
tine, the  right  side  bulges  out  in  a  globular  and  almost  hernial  form. 
This  condition  is  more  common  in  advanced  life,  and  in  strurna  and 
phthisis  ;  and  we  have  observed  that  by  the  contraction  of  a  cicatrix 
this  sacculated  portion  has  become  almost  shut  off,  so  as  to  render 
the  passage  from  the  ileum  to  the  ascending  colon  about  the  size  of 
the  ileum  itself. 

Distension. — Abnormal  distension  of  the  caecum  is  sometimes  the 
consequence  of  obstruction  in  the  colon,  or  its  own  muscular  pari- 
etes  contract  with  less  than  their  wonted  vigor,  and  then  it  easily 
becomes  distended  by  the  accumulation  of  feces  or  of  flatus.  It  is 
probable  that  diminished  secretion  from  the  appendix  caeci  may 
favor  this  accumulation  of  feces,  which  is  often  amongst  the  exciting 
causes  of  serious  disease,  and  requires  attention.  Considerable  fecal 
distension  in  the  caecum,  and  ascending  colon  produces  pain  in  the 
iliac  region,  and  by  pressure  on  the  last  dorsal  and  genito-crural 
nerve,  induces  pain  also  over  the  hip,  as  far  as  the  great  trochanter, 
the  groin,  and  the  testicle,  &c. 

The  pain  thus  produced  is  sometimes  of  an  acute  character,  re- 
sembling colic,  and  it  may  excite  considerable  alarm.  Dr.  Copland 
mentions  oedema  of  the  right  leg  as  a  result  of  distended  caecum ; 
this  I  have  not  observed,  except  with  very  feeble  power,  or  a  vari- 
cose condition  of  the  veins.  Pressure  of  this  kind  would,  doubtless, 
perpetuate  and  aggravate  a  varicose  condition  of  the  veins  of  the 
lower  extremity. 

Many  instances  of  pain  in  the  region  of  the  caecum  arise  from  dis- 
tension^ and  the  symptoms  entirely  disappear  when  the  colon  is  gently 
but  freely  acted  upon,  and  emptied. 

(Edema  of  the  mucous  membrane  is  often  observed  with  renal 
anasarca,  and  with  long-continued  congestion  of  the  vena  portae. 

Congestion.— The  depending  position  of  the  vessels  often  produces 
a  passive  fulness  of  the  capillaries  of  this  part  of  the  alimentary 
canal ;  but  we  also  find  an  active  congestion,  as  shown  by  arbores- 
cent injection  of  the  minute  vessels.  This  is  probably  sometimes 


316  ON    DISEASES    OP    THE    CJECUM 

produced  by  medicine  administered  a  short  time  before  death;  as  the 
elaterium  powder  in  ascites,  renal,  hepatic,  or  pulmonary  disease,  or 
it  is  the  result  of  the  transmission  of  irritating  substances  and  secre- 
tions from  the  small  intestine,  as  an  excess  of  bile  or  excreta  of  an 
acrid  character,  or  from  undigested  food. 

Inflammation. — Typhlitis.  The  distension  of  the  caecum,  to  which 
we  have  previously  referred,  induces  local  enteritis,  namely,  inflam- 
mation of  the  mucous  membrane  of  the  caecum,  and  of  the  peritoneum 
which  invests  the  part.  A  numerous  class  of  cases  is  thus  constituted, 
which  are  happily  more  tractable  than  those  in  which  peritonitis  is 
set  up  by  a  concretion  in  the  appendix  caeci.  The  mucous  mem- 
brane is  congested,  its  secretion  altered,  the  feces  become  adherent, 
the  muscular  coat  is  unable  to  propel  the  contents,  which  constitute 
a  tumor  felt  on  palpation,  and  the  inflamed  peritoneum  produces  ten- 
derness. In  most  cases,  this  tumor  consists  of  portions  of  intestine 
united  by  inflammatory  adhesions,  and  in  still  more  rare  instances 
it  is  composed  of  effusion  behind  the  csecum,  in  the  iliac  fossa. 

The  direct  continuity  of  mucous  membrane  from  the  ileum  ap- 
pears in  many  cases  to  allow  the  extension  of  disease  to  the  crocum, 
which  in  all  probability  would  not  otherwise  occur ;  we  find  this  in 
enteric  fever  and  in  strumous  disease,  in  which  the  ileo-colic  valve 
is  often  acutely  inflamed,  swollen,  injected,  and  ulcerated. 

The  caecum  is  also  found  acutely  inflamed  in  some  cases  of  dysen- 
tery ;  it  becomes  injected,  the  mucus  scanty,  the  feces  adherent,  or 
the  surface  covered  with  a  delicate  false  membrane ;  it  is  here 
affected  as  a  part  of  the  colon  from  continuity  of  structure. 

Gray  Discoloration. — This  is  liable  to  occur  from  any  chronic  dis- 
ease either  congestive  or  inflammatory.  It  is  sometimes  general,  at 
other  times  it  constitutes  minute  zones  around  the  solitary  glands ; 
or  there  are  small  circular  ulcers,  which  have  originated  in  disease 
of  the  solitary  glands,  or  mucous  follicles,  around  which  this  gray 
deposition  has  taken  place. 

A  granular  condition  of  the  mucous  membrane,  as  if  minutely 
studded  with  particles  of  sand,  has  been  already  alluded  to  and  ap- 
pears to  be  the  result  of  long-continued  slight  inflammation,  asso- 
ciated with  thickening  of  the  mucous  and  sub-mucous  coats. 

Ukeration  of  the  caecum  is  rare  as  a  disease  simply  affecting  this 
part,  but  when  associated  with  other  morbid  states  it  is  of  frequent 
occurrence ;  thus  in  phthisis,  tubercle  is  deposited,  and  as  a  conse- 
quence ulceration  is  often  observed  in  the  mucous  membrane ;  so 
also  in  enteric  fever,  it  is  not  unfrequent  to  find  some  scattered  ulcers 
in  the  caecum.  In  dysentery  also,  the  caecum  is  not  only  acutely 
inflamed,  as  before  mentioned,  but  it  frequently  presents  extensive 
ulceration^  sometimes  a  transverse  ulcer  is  found  to  present  ragged 
and  injected  margins ;  at  other  times  the  mucous  membrane  is  even 
in  a  sloughing  state,  or  suppuration  takes  place  between  the  layers 
of  the  intestines,  as  was  found  in  a  remarkable  degree  in  one  of  the 
cases  of  dysentery  subsequently  detailed.  In  the  acute  inflammation 
and  ulceration  of  the  colon  consequent  on  the  taking  of  poisonous 
substances,  as  arsenious  acid  or  corrosive  sublimate,  the  rectum  and 


AND    APPENDIX    C^CT.  317 

sigmoid  flexure  are  generally  more  severely  affected  than  the  caecum 
and  ascending  colon;  this,  however,  is  not  invariably  the  case. 
Again,  ulceration  is  often  present  from  over-stretching,  as  we  have 
frequently  found  in  obstruction  of  the  sigmoid  flexure ;  the  mucous 
membrane  yields  in  transverse  lines,  as  when  the  skin  has  been  simi- 
larly over- stretched  and  ulcerates. 

In  several  instances  of  enteritis  affecting  this  part'of  the  intestine, 
or  typhlo-enteritis  as  it  is  sometimes  termed,  the  peritoneum  becomes 
also  involved ;  this  may  arise  from  the  propagation  of  the  disease 
from  the  mucous  to  the  serous  layer,  or  from  rupture  of  the  intesti- 
nal coats ;  but  perforation  into  the  peritoneal  cavity  is  more  fre- 
quently found  to  arise  from  disease  of  the  appendix  than  from  sim- 
ple ulceration  of  the  caecum  ;  extravasation  and  sudden  fatal  peri- 
tonitis, even  when  perforation  has  taken  place,  may,  however,  be 
prevented  by  adhesions;  or  if  these  adhesions  be  less  extensive, 
fecal  abscess  is  formed.  We  shall  again  have  to  refer  more  fully  to 
perforation  of  the  appendix  caeci  from  ulceration  variously  produced. 
The  peritonitis  which  ensues  when  no  adhesions  exist,  is  almost  as 
sudden  in  its  symptoms,  and  as  fatal  in  its  results,  as  perforation  of 
the  stomach ;  but  in  cases  much  more  numerous  than  is  generally 
supposed,  extravasation  is  prevented  \)y  antecedent  adhesions,  as 
has  been  shown  by  M.  Leudet,  the  accuracy  of  whose  observations  I 
can  fully  confirm.  But  perforation  from  ulceration  may  take  place 
on  the  attached  surface  of  the  intestine  behind  the  peritoneum;  the 
disease  then  extends  into  the  cellular  tissue  in  the  iliac  fossa ;  pus 
burrows  beneath  the  fascia,  and  forms  an  opening  near  the  anterior 
superior  spinous  process  of  the  ileum,  in  the  loin,  or  below  Poupart's 
ligament  on  the  thigh,  or  it  may  pass  upwards  behind  the  ascending 
colon,  and  may  reach  the  under  surface  of  the  liver.  These  cases 
are,  however,  rare ;  and  ulceration  of  the  appendix  much  more  fre- 
quently leads  to  adhesions  of  the  peritoneum,  to  fecal  abscess,  or  to 
general  peritonitis. 

Cancerous  disease  not  unfrequently  attacks  the  caecum ;  sometimes 
the  ileo-caecal  valve  presents  an  appearance  similar  to  that  found  in 
like  disease  at  the  pylorus,  and  an  extensive  cancerous  ulcer  is  found 
to  extend  upon  the  anterior  or  posterior  surface  of  the  caecum  ;  when 
the  former  course  is  followed,  peritoneal  adhesion  or  inflammation 
takes  place ;  and  when  the  latter,  the  cellular  tissue  in  the  iliac  fossa 
is  involved,  and  suppuration  sometimes  occurs ;  in  either  case  fecal 
abscess  and  artificial  anus  may  be  produced. 

Cancerous  disease  manifests  itself  under  different  forms;  it  may 
be  of  a  scirrhous  character  and  slow  in  its  growth.  This  variety  is 
more  likely  to  lead  to  chronic  obstruction,  and  is  then  associated 
with  dilatation  of  the  intestine  and  hypertrophy  of  its  muscular  coat. 
Sometimes,  indeed,  there  is  so  much  fibrous  tissue  deposited  that  it 
is  difficult  to  find  true  cancerous  product;  and  it  may  be  doubted 
whether  these  cases  are  not  at  first  inflammatory  obstruction,  upon 
which  cancer  is  engrafted.  We  have  alluded  to  parallel  cases  when 
speaking  of  the  relation  of  chronic  ulcer  of  the  stomach  to  cancerous 
disease.  On  the  contrary,  the  disease  is  sqmetimes  soft  and  funga- 


318  ON    DISEASES    OF    THE    C^CUM 

ting,  and  has  the  microscopical  and  general  appearance  of  a  medullary 
growth.  Again,  epithelioma  and  colloid  cancer  are  occasionally  ob- 
served. The  disease  has  a  greater  tendency  to  extend  along  the 
coats  of  the  caecum  itself  than  to  pass  backwards  into  the  ileum.  In 
lymphadenoma  the  thickening  of  the  coats  of  the  intestine,  and 
dilatation  of  the  canal,  are  often  well  marked.  It  may  be  further 
remarked  that  the  caecum,  is  less  frequently  affected  with  cancer  than 
the  sigmoid  flexure  and  the  rectum. 

The  Tricocephalus  dispar  is  described  as  being  frequently  present 
in  the  caecum.  I  have  only  observed  them  about  three  times  from 
many  hundreds  of  inspections,  in  very  many  of  which  the  intestines 
were  examined  throughout  with  care. 

APPENDIX.  Increase  of  length. — The  appendix  is  sometimes  five 
or  six  inches  in  length,  and  perfectly  free  in  its  movements.  It  may 
be  free  among  the  coils  of  the  small  intestine,  or  in  other  cases  it 
becomes  adherent  to  the  brim  of  the  pelvis,  to  the  parietes  of  the 
abdomen,  or  to  the  mesentery.  In  this  way  loops  are  formed,  which 
in  many  cases  become  the  cause  of  fatal  internal  strangulation,  a 
portion  of  small  intestine  passing  beneath  the  band  thus  formed. 
Cases  have  been  recorded  of  the  appendix  being  found  in  a  hernial 
sac. 

Atrophy. — The  orifice  of  the  appendix  in  occasionally  obliterated, 
and  the  appendix  itself  bound  down  by  adhesions ;  in  this  way  it 
becomes  wasted,  and  at  last  almost  destroyed. 

Dilatation  takes  place  from  obstruction  at  or  near  the  orifice,  so 
that  the  secretion  is  unable  to  make  its  escape ;  the  canal  then  di- 
lates, and  becomes  one-fourth  to  one-half  of  an  inch  in  diameter ; 
the  walls  are  sometimes  thickened,  and  the  muscular  coat  hyper- 
trophied,  as  if  the  attempt  had  been  made  to  overcome  the  obstruc- 
tion, or,  on  the  contrary,  it  becomes  exceedingly  thinned  almost  to 
perforation;  when  so  dilated  it  is  filled  with  thin  mucus,  and  the 
follicles  have  the  appearance  of  minute  semi-transparent  cysts. 

Concretions. — Substances  of  diverse  character  are  found  lodged  in 
the  appendix  caeci,  and  whilst  sometimes  harmless,  they  often  pro- 
duce very  serious  consequences.  Some  are  extraneous,  others  are 
entirely  formed  within  the  canal  itself;  and,  lastly,  there  are  those 
which  have  a  nucleus  consisting  of  some  foreign  substance,  but 
covered  over  by  layers  of  concretion,  from  the  irritation  produced. 

1.  Extraneous  bodies  are  found,  consisting  of  nails,  pins,  stones  of 
fruit,  shot,  bristles,1  entozoa,  and  most  frequently,  feces. 

2.  Concretions,  as  of  albuminous  mucus,  are  formed  in  the  appen- 
dix.    These  are  not  uncommon,  and  constitute  firm  semi-transparent 
masses,  which,  when  dry,  are  fragile,  and  free  from  earthy  matter. 

3.  Calculi,  which  generally  present  a  nucleus  of  feces,  or  of  some 
foreign  body. 

I  have  frequently  found  the  appendix  filled  with  feces ;  sometimes 
in  its  whole  length,  or  only  forming  one  or  more  hard  nodules. 

1  '  Transactions  of  Pathological  Society,'  1855.     Mr.  N.  Ward's  case. 


AND    APPENDIX    C.ECI.  319 

These  minute  fecal  masses  frequently  constitute  the  nuclei  of  calculi, 
and  become  encrusted  with  layers,  composed  of  carbonate  and  phos- 
phate of  lime,  according  to  the  analyses  of  Dr.  Odling  and  of  the  late 
Dr.  Golding  Bird.  A  concretion,  examined  by  Dr.  Prout,  was  found 
to  consist  of  phosphate  of  lime,  with  a  little  carbonate,  and  contained 
a  small  quantity  of  animal  and  oleaginous  matter.1  Thus  consti- 
tuted, layer  after  layer  becomes  applied,  till  the  size  of  a  cherrystone 
is  attained  ;  and  many  of  the  so-called  cherry  stones  in  the  appendix 
are  thus  formed.  The  calcareous  matters  appear  to  be  derived  from 
the  mucous  membrane  itself  in  the  same,  manner  as  a  calculus  in  the 
urinary  bladder  becomes  encrusted  with  phosphate  of  lime  from  the 
abundant  mucus  thrown  out  from  the  irritated  surface.  In  some 
cases  a  larger  size  is  attained,  and  the  mass  becomes  as  large  as  a  date- 
stone  or  a  hen's  egg.  In  the  museum  of  Guy's  (No.  189325)  is  a  large 
calculus  the  size  of  a  hen's  egg,  the  surface  of  which  is  rounded  and 
fissured ;  it  was  removed  from  a  sinus  leading  from  the  parietes  of 
the  abdomen  to  the  caecum ;  no  appendix  was  found,  but  a  large 
abscess  extended  from  the  caecum  to  the  liver.  The  calculus  was 
composed  of  phosphate  of  lirne,  with  alkaline  chlorides. 

In  some  it  is  very  difficult  to  discover  a  nucleus,  a  white  laminated 
substance  being  present  throughout.  The  nucleus,  however,  may  be 
exceedingly  small,  as  in  a  case  described  by  Mr.  N.  Ward,  where 
the  bristle  of  a  tooth-brush  formed  the  centre  of  a  calculus;  or  it 
may  be  a  portion  of  pin,  or  a  hair. 

Diminished  contractile  power  of  the  muscular  coat,  with  distension 
of  the  intestine,  are  the  probable  causes  of  the  propulsion  of  feces 
into  the  appendix,  usually  determined  by  some  sudden  muscular 
effort;  or  it  may  be  that  the  peristaltic  contraction  is  rendered 
irregular  by  an  irritated  condition,  from  acrid  and  crude  materials 
impelled  into  the  caecum,  and  that  this  irregularity  of  action  causes 
the  feces,  perhaps  more  fluid  than  normal,  to  pass  into  the  appendix. 
In  whatever  way  produced,  any  concretion  in  this  part  may  lead  to 
very  serious  results. 

I.  It  excites  irritation  and  ulceration  of  the  mucous  membrane. 

II.  This  ulceration  may  extend  through  the  muscular  coat,  and 
often  through  the  peritoneum. 

III.  Inflammatory  action  consequent  on  the  perforation  may  be 
of  a  purely  local  character:    effusion  of  fibrinous  material  takes 
place,  and  adhesions  form,  which  prevent  extension  to  the  general 
surface  of  the  peritoneum.     Coils  of  the  small  intestine  may  be  thus 
firmly  united  to  the  caecum,  and  constitute  a  compact  mass,  felt  on 
manual  examination  of  the  abdomen. 

IV.  The  inflammatory  action,  although  local^may  produce  a  less 
organizable  product;  and  suppuration  may  take'  place,  constituting 
an  abscess,  into  which  a  greater  or  less  quantity  of  feces  may  escape. 
The  subsequent  course  of  this  abscess  may  vary  much: — 1.  It  may 
resolve  into  a  dried  mass  of  semi-calcareous  product.      2.    After 
sudden  exertion  the  adhesions  which  localize  the  pus  may  break 

'  '  Medical  Gazette,'  vol.  vi. 


320  ON    DISEASES    OF    THE    C2ECUM 

down,  and  extravasation  take  place  into  the  general  cavity  of  the 
peritoneum,  with  a  speedily  fatal  result.  3dly.  It  may  pass  into 
the  intestine  by  a  second  opening,  and  thus  be  harmlessly  discharged. 
This  opening  may  be  into  the  ascending  colon  or  the  ileum,  and  in 
a  specimen  in  the  Guy's  Hospital  Museum,  an  elongated  and  ulce- 
rated appendix  had  opened  into  the  rectum.  4thly.  It  may  burrow 
down  into  the  pelvis;  or  the  cellular  tissue  behind  the  caecum  may 
become  involved,  the  abscess  extending  sometimes  upward  behind 
the  ascending  colon,  or  down  towards  Poupart's  ligament.  In  the 
latter  case  the  opening  is  either  below  that  ligament,  or  near  the 
anterior  and  superior  spinous  process  of  the  ileum. 

In  a  case  under  Dr.  Barlow's  care,  in  Guy's,  this  ulcerative  exten- 
sion of  caecal  disease  destroyed  a  part  of  the  wall  of  the  iliac  artery, 
and  led  to  almost  immediate  death,  from  the  sudden  and  uncontrolla- 
ble hemorrhage. 

Abscesses  of  this  kind  sometimes  contain  feees;  but,  even  if  they 
have  an  external  opening,  it  is  difficult  to  procure  their  complete 
evacuation;  and  we  have  but  little  chance  of  preventing  repeated 
attacks  of  inflammatory  action.  The  strength  at  last  gives  way  or 
life  is  cut  short  by  intense  and  general  peritonitis. 

V.  The  perforation  sometimes  takes  place  directly  into  the  peri- 
toneum, and  sets  up  peritonitis  so  severe  and  general,  that  a  fatal 
result  follows  in  a  few  hours,  or  at  most  in  a  few  days. 

The  position  of  the  concretion,  whether  fecal  or  otherwise,  varies; 
sometimes  it  is  quite  at  the  termination  of  the  appendix,  at  other 
times  close  to  the  opening  into  the  caecum.  Fecal  masses  are  also 
found  adherent  beneath  the  ileo-colic  valve,  and  in  sacculated  de- 
pressions on  the  surface  of  the  caecum;  but  I  have  never  witnessed 
true  concretions  in  these  parts  as  in  the  appendix. 

In  strumous  patients,  these  concretions  more  readily  tend  to  an 
unfavorable  result,  leading  to  perforation,  and  to  fecal  abscess  or 
peritonitis.  But  it  must  not  be  assumed  in  such  cases  that  because 
there  is  perforation  therefore  there  has  been  a  concretion,  the  appen- 
dix may  be  itself  the  seat  of  ulceration,  without  the  irritation  of 
concretions ;  and  especially  so  in  strumous  subjects.  In  phthisis  it 
is  very  common  to  find  ulceration  in  the  appendix  caeci,  from  the 
degeneration  of  tubercle  ;  sometimes  several  small  ulcers  are  present, 
at  other  times  the  appendix  is  almost  cut  in  two.  This  condition 
sometimes  leads  to  fatal  peritonitis  in  the  earliest  stage  of  phthisis. 

Symptoms. — The  symptoms  of  some  of  these  pathological  condi- 
tions have  been  already  alluded  to ;  others  afford  no  sign  indicative 
of  their  presence  during  life,  and  after  death  conditions  are  found 
which  would  have  acted  as  disturbing  causes,  predisposing  to  serious, 
if  not  to  fatal  disease,  if  life  had  been  prolonged. 

Distension  of  the  caecum  is  indicated  by  fulness  and  pain  in  the 
iliac  region,  especially  when  the  erect  posture  is  assumed,  or  after 
walking;  it  is  generally  accompanied  by  fulness  in  that  part,  dulness 
on  percussion,  and  slight  febrile  excitement  with  congested  portal 
circulation,  and  with  loaded  colon.  Hence,  we  often  find  other 
symptoms  present,  not  arising  from  the  caecum,  but  from  associated 


AND    APPENDIX    C^ECI.  321 

disease ;  thus  depression  of  mental  energy,  sallow  complexion,  furred 
tongue,  offensive  breath,  pain  in  the  head,  arise  not  from  the  condition 
of  the  caecum,  but  from  the  retention  in  the  blood  of  waste  material, 
which  would  be  thrown  off,  if  the  liver  and  excretory  glands  of  the 
whole  alimentary  canal  rightly  performed  their  functions.  The 
mechanical  distension,  however,  sometimes  by  its  pressure  leads  to 
pain  in  the  loins,  or  in  the  course  of  the  last  dorsal  or  genito-crural 
nerve,  the  pain  extending  over  the  dorsum  of  the  ileum,  or  into  the 
groin  or  testicle ;  in  women  this  pressure  may  interfere  with  the 
proper  function  of  the  ovaries  and  uterus. 

Typhlitis. — Irritation  or  inflammation  of  the  mucous  membrane  of 
the  caecum  may  be  productive  of  diarrhoea.  Such  cases  are  generally 
associated  with  but  slight  pain  in  the  region  of  the  caecum.  This 
form  of  disease  is,  however,  in  most  cases,  only  part  of  a  more  gene- 
ral affection  of  the  mucous  membrane ;  as  in  bilious  diarrhoea,  from 
acrid  excreta,  in  dysentery,  and  in  struma;  disease  of  the  mucous 
membrane  alone  is  not  productive  of  pain.  If  all  the  coats  be 
affected,  or  ulceration  have  taken  place,  a  very  marked  train  of 
symptoms  follows.  After  some  irregularity  of  the  bowels,  either 
diarrhoea  or  constipation,  generally  the  latter,  and  perhaps  after 
more  than  wonted  exertion,  severe  pain  comes  on,  in  many  cases 
suddenly,  in  the  right  iliac  fossa.  It  may  be  confined  to  this  spot, 
and  be  accompanied  by  excessive  tenderness,  radiating  over  the  abdo- 
men, and  be  very  quickly  followed  by  collapse,  and  the  signs  of 
general  peritonitis,  or  the  tenderness  and  pain  in  the  neighborhood 
of  the  caecum  are  accompanied  with  fulness  and  slight  dulness  on 
percussion.  There  are  febrile  symptoms,  the  skin  is  hot,  temperature 
102°-10±°,  the  tongue  is  slightly  furred,  the  pulse  is  often  compres- 
sible and  somewhat  excited,  and  local  peritonitis  is  set  up  in  connec- 
tion with  ulceration  or  inflammation  of  the  coats  of  the  caecum. 
These  are  the  symptoms  of  what  has  been  called  typhlo-enteritis. 
There  is  often  a  gradual  subsidence  of  these  symptoms,  the  pain  and 
distress  cease,  the  fulness  disappears,  the  bowels  return  to  healthy 
action,  and  the  patient  is  restored  to  health.  In  other  cases  the 
fulness,  tenderness,  and  pain  continue,  and  a  more  defined  tumor  is 
perceptible ;  repeated  attacks  of  severe  pain  come  on,  and  gradual 
loss  of  strength,  or  sudden  accession  of  fatal  and  general  peritonitis. 
The  local  peritonitis  has  in  these  cases  given  rise  to  suppuration  or 
to  fecal  abscess;  and  perforation  of  this  abscess  is  the  cause  of  the 
sudden  collapse  and  speedy  death.  Or,  we  may  have  the  same  result 
as  before  described,  but  retarded  for  a  time  by  local  adhesions. 
Again,  instead  of  peritonitis,  diarrhoea  may  be  set  up,  irritability  of 
stomach,  injected  and  brown  tongue,  failing  pulse,  and  the  ordinary 
symptoms  of  hectic  fever.  But  even  from  this  condition  recovery 
sometimes  takes  place,  by  the  discharge  of  pus  from  the  peritoneal 
abscess  into  the  intestine  itself,  or  through  the  abdominal  panetes ; 
or  by  the  absorption  of  the  fluid  parts  of  the  pus,  when  a  semi-creta- 
ceous mass  is  left;  if,  however,  fecal  abscess  have  formed,  recurrent 
attacks  of  peritonitis,  with  increasing  prostration,  generally  lead 
a  fatal  result. 
21 


322  ON    DISEASES    OF    THE    CAECUM 

In  those  cases  where  sudden  perforation  of  the  caecum  or  appendix 
takes  place  there  are  scarcely  any  premonitory  symptoms;  the  pa- 
tient is  struck  down  in  fatal  collapse,  resembling  the  equally  fatal 
case  of  perforation  of  the  stomach.  In  these  cases  the  pain  is  not 
necessarily  situated  in  the  region  of  the  caecum,  but  above,  nearer 
the  stomach ;  conversely  I  have  seen  a  case  where  the  pain  preceding 
fatal  collapse  was  in  the  region  of  the  caecum,  when  the  perforation 
arose  in  the  stomach.  It  is  difficult  to  explain  this  occasional  event. 
but,  generally  speaking,  the  pain  is  situated  in  the  neighborhood  of 
the  diseased  viscus. 

In  cancerous  disease  of  the  caecum,  the  symptoms  are  very  similar 
to  those  already  described,  namely,  pain  and  fulness  in  the  region  of 
the  caecum,  tenderness  on  pressure,  and  a  more  or  less  distinct  tumor; 
there  is  diarrhoea  or  constipation,  but  generally  the  latter;  the  ciecal 
pain  is  often  greatly  aggravated  by  food,  especially  of  a  fluid  kind  ; 
and  the  accession  of  pain  is  sometimes  found  to  arise  directly  after 
the  nourishment  has  been  taken;  the  febrile  symptoms  are,  however, 
less  decided,  and  the  pain  is  of  a  less  severe  character. 

There  is  a  greater  tendency  to  the  local  form  of  disease  in  early 
manhood  than  in  later  life.  Many  cases  occur  under  20,  but  the 
disease  is  not  rare  at  later  periods  of  life,  30,  40,  or  50  years  of  age. 

Diagnosis. — In  the  diagnosis  of  inflammation  of  the  caecum  it  must 
be  borne  in  mind  (1),  that  simple  excessive  distension  of  the  ccecuin 
is  sometimes  accompanied  with  severe  pain. 

2.  That  after  blows  on  the  abdominal  parietes,  or  from  other  causes, 
suppuration  sometimes  takes  place  in  the  cellular  tissue,  or  even  in 
the  muscles  of  the  iliac  fossa,  and  may  be  accompanied  by  local  pain 
or  peritonitis  without  caecal  disease. 

8.  That  suppuration  connected  with  the  right  kidney,  or  its  en- 
velopes, sometimes  extends  into  the  iliac  fossa. 

4.  That  we  may  have  disease  of  the  vertebrae,  or  iliac  bones,  lead- 
ing to  suppuration  in  the  iliac  fossa. 

5.  Pain  arises  in  the  course  of  the  last  dorsal  nerve  from  diseased 
spine,  or  in  the  course  of  the  genito- crural  nerve  from  renal  calculus, 
and  might  be  confounded  with  caecal  inflammation. 

6.  Inflammatory  disease  in  connection  with  ths  ovaries,  leading  to 
local  peritonitis  and  severe  pain,  is  frequently  mistaken  for  cuecal 
disease. 

7.  Cancerous  disease  of  the  caecum,  and 

8.  Disease  of  the  ileurn  in  struma  or  after  typhoid  fever,  as  well 
as 

9.  Strurnous  peritonitis  must  each  be  remembered  in  forming  a 
correct  diagnosis. 

10.  I  have  known  cases  where  the  peritonitis  from  caecal  perfora- 
tion was  regarded  at  first  as  gall-stone,  the  sudden  pain  on  the  right 
side,  with  violent  vomiting,  closely  simulating  the  symptoms  of  that 
disease. 

Dr.  Battersby,  in  a  very  interesting  paper  in  the  '  Dublin  Quar- 
terly' of  1857,  refers  to  other  fallacies,  as  hernia,  disease  of  the  hip, 
and  of  the  genital  organs. 


AND    APPENDIX    C^ECI.  328 

The  pain  in  simple  distension  of  the  caecum  is  less  severe  than  in 
acute  inflammation.  Disease  in  the  parietes  in  a  very  short  time 
manifests  its  local  character;  but  at  first  the  diagnosis  is  obscure, 
and  the  mere  fecal  odor  of  pus  does  not  necessarily  imply  communi- 
cation with  the  intestine.  The  pain  and  swelling  connected  with 
suppuration  of  the  spine  or  kidney  differ  in  position  ;  with  the  kidney 
they  are  more  in  the  loins,  or,  if  extending  anteriorly,  they  are  nearer 
to  the  median  line.  Spinal  suppuration  extends  beneath  the  iliac 
fascia,  and  would  be  distinguished  from  caecal  abscess  burrowing  be- 
neath Poupart's  ligament,  by  the  fecal  character  of  the  discharge  in 
the  latter. 

The  neuralgic  pains  connected  with  urino-genital  disease  are  not 
accompanied  with  the  tenderness  or  the  other  symptoms  of  intestinal 
affection.  It  is,  however,  sometimes  difficult  to  distinguish  inflamma- 
tory disease  about  the  right  ovary  from  caecal  disease.  There  may  be 
in  both  excessive  tenderness,  febrile  excitement,  constipation,  severe 
pain  in  the  lower  part  of  the  iliac  fossa.  The  symptoms  which  will 
serve  to  guide  us  are,  that  the  ovarian  disease  comes  on  with  irregular 
menstruation  or  with  sudden  cessation  of  that  flux,  and  that  the  pain 
is  situated  lower  down  in  the  hypogastric  region;  in  some  cases, 
observers  have  believed  that  they  have  felt  the  swollen  ovary.  Dr. 
Barlow  records  a  case  in  which  peritonitis  of  so  severe  a  character 
was  set  up  around  an  inflamed  ovary,  that  the  patient  succumbed. 
In  cancerous  disease  of  the  caecum,  which  sometimes  occurs  in  young 
subjects,  it  is  almost  impossible,  unless  there  be  indication  of  cancer- 
ous disease  in  other  parts,  rightly  to  diagnose  its  character.  These 
are,  however,  rare  cases.  In  strumous  peritonitis  the  disease  is  not 
confined  to  one  part  of  the  abdomen,  but  in  severe  cases  the  intestines 
are  so  completely  united  by  peritoneal  adhesions  as  to  move  en  masse. 
It  is  impossible  to  distinguish  perforation  of  the  ileum  in  struma  or 
phthisis  from  perforation  of  the  appendix  caeci;  this  is,  however,  of 
little  moment,  since  the  only  remedial  agents  which  are  likely  to  be 
of  service  in  these  almost  universally  fatal  cases  are  precisely  similar 
in  both. 

Prognosis. — In  cases  of  caecal  distension,  when  the  mucous  mem- 
brane only  is  affected  without  ulceration,  our  prognosis  is  generally 
a  favorable  one,  unless  we  find  the  patient  of  a  strumous  habit,  in 
which  case  there  is  greater  tendency  to  ulceration  and  perforation. 
When,  again,  there  are  the  symptoms  of  local  peritonitis,  many 
patients  do  well ;  the  reverse,  however,  is  the  case  when  the  onset 
of  the  disease  is  marked  by  severe  collapse,  or  by  urgent  vomiting 
and  by  general  abdominal  pain. 

Causes. — The  predisposing  causes  are  a  strumous  diathesis,  seden- 
tary habits,  habitual  constipation,  typhoid  fever,  &c. 

The  exciting  causes  are,  over  exercise,  much  standing,  violent 
athletic  exercises ;  in  many  cases  caecal  disease  has  come  on  after 
very  long  pedestrian  excursions,  after  indigestible  food  has  been 
taken,  after  blows  upon  the  abdomen,  after  constipation,  or  an 
irregular  condition  of  the  bowels. 


324  ON    DISEASES    OF    THE    C^ICUM 

Treatment. — I  cannot  urge  in  too  strong  language  the  importance 
of  avoiding  in  csecal  disease  powerful  drastic  purgatives.  They  tend 
to  increase  the  disease  by  inducing  violent  peristaltic  action;  by 
increasing  the  irritation  of  an  already  inflamed  membrane  they 
hasten  ulceration ;  and  if  ulceration  have  taken,  place,  or  if  peri- 
tonitis have  resulted,  the  only  hope  of  the  patient  would  be  taken 
away  by  these  remedies. 

If  there  be  simple  distension,  with  only  very  slight  pain  in  the 
erect  posture,  we  should  enjoin  rest,  and  administer  gray  powder 
with  Dover's  powder,  followed  by  a  dose  of  castor-oil,  or  by  a  castor- 
oil  enema ;  afterwards  mild  aperient  tonics,  as  the  compound  gentian 
mixture,  are  useful. 

If  tenderness  exist,  or  there  be  the  symptoms  of  local  peritonitis, 
rest  is  still  more  positively  required ;  the  patient  should  not  move 
from  the  bed  on  any  consideration.  Local  depletion  is  exceedingly 
valuable ;  ten  or  fifteen  leeches  applied  to  the  region  of  the  caecum, 
and  warm  fomentations,  are  often  followed  by  most  marked  benefit. 
At  the  same  time  mild  mercurials  may  be  administered,  with  opium, 
such  as  equal  parts  of  gray  powder  and  Dover's  powder,  or  small 
doses  of  calomel  with  opium  ;  but  I  prefer  opium  or  Dover's  powder 
without  the  mercury.  These  remedies  may  be  combined  with  saline 
medicines,  with  the  acetate  of  ammonia  and  bicarbonate  of  potash 
or  nitric  ether,  according  to  circumstances.  But  little  food  should 
be  taken,  and  only  of  bland  unstimulating  kind.  When  the  pain 
has  subsided,  and  the  febrile  excitement  has  disappeared,  the  patient 
is  often  tempted  to  try  and  get  out  of  bed  and  use  slight  muscular 
effort ;  but  this  is  exceedingly  injudicious,  and  is  sometimes  followed 
by  a  fatal  result. 

The  remedies  just  mentioned  often  induce  action  on  the  bowels ; 
but  if  not,  although  the  pain  may  have  subsided,  it  is  better  to  wait, 
than  to  administer  even  a  gruel  or  castor-oil  injection,  still  less  than 
to  give  more  powerful  purgatives,  as  aloes,  jalap,  senna,  colocynth, 
scammony,  &c. 

•  If  there  be  persistence  of  slight  pain,  with  fulness  and  dulness,  it 
is  well  to  continue  the  opium,  and  a  blister  may  be  applied  to  the 
illiac  region. 

Iodide  of  potassium  and  mild  vegetable  tonics  are  afterwards  of 
great  service,  rest  being  still  maintained.  Irritability  of  stomach 
sometimes  arises,  and  may  be  alleviated  by  saline  effervescing  medi- 
cine, by  hydrocyanic  acid,  by  soda-water  with  milk,  or  with  brandy,  &c. 

If  there  be  evidence  of  suppuration  or  of  fecal  abscess,  whilst  we 
endeavor  to  limit  the  action  by  slight  counter-irritants,  or  by  occa- 
sional local  depletion,  we  must" sustain  the  power  of  the  patient  by  a 
generous  diet,  by  quinine,  and  by  tonic  treatment.  Opium  is  often 
of  great  value  by  its  anodyne  and  narcotic  effect,  in  checking  peris- 
taltic action,  in  relieving  pain,  in  soothing  an  over-excited  nervous 
system,  in  diminishing  the  irritability  of  exhaustion,  and  often  in 
procuring  refreshing  sleep. 

When  there  is  collapse  and  tympanitis,  evincing  perforation  of  the 
appendix  or  intestine,  nothing  should  induce  us  to  administer  any 


AND    APPENDIX    C.ECI. 


325 


aperient,  or  to  urge  an  action  from  the  bowels.  We  desire  to  limit 
the  mischief  produced  by  checking  the  movement  of  the  intestines, 
and  to  diminish  inflammatory  action  by  soothing  the  nervous  sys- 
tem ;  opium  must  be  given  very  freely,  and  only  a  very  small  quan- 
tity of  food  administered. 

Cases. — Abnormal  position  of  the  caecum  ;  several  were  connected 
with  fatal  obstruction,  and  a  similar  instance  is  recorded  bv  Mr. 
Avery,  in  the  'Pathological  Transactions'  for  1850,  where  the  opera- 
tion for  artificial  anus  was  performed. 

CASE  CIII.  Unusually  Free  Ccecum — A  boy,  aet.  5,  died  from  loss  of 
blood  consequent  upon  an  accidental  wound  of  his  internal  jugular  vein. 

CASE  CIV.  Unusually  Free  Ccecum — A  young  woman  died  after  a  mis- 
carriage. 

The  viscera  were  healthy,  but  the  caecum  was  situated  among  the  small 
intestines,  quite  surrounded  by  peritoneum,  and  as  free  as  a  portion  of  the 
ileuni. 

The  ccecum  was  attached  by  a  long  mesentery  to  the  right  side  of  the 
spinal  column,  so  that  the  whole  iliac  fossa  was  perfectly  free,  and  covered  by 
peritoneum. 

Such  conditions  are  congenital.  They  are  of  importance  in  modi- 
fying symptoms  of  subsequent  disease. 

CASE  CV.  Ccecum  inverted. — A  man,  aet.  42,  died  from  phthisis,  local 
empyema,  and  chronic  tubal  nephritis. 

On  examining  the  intestine,  the  appendix  caeci  was  found  to  be  long,  and 
extending  over  the  brim  of  the  pelvis,  where  it  was  fixed.  The  rounded 
termination  of  the  caecum  was  directed  towards 
the  diaphragm  as  if  inverted.  The  ascending 
colon  was  contracted,  and  attached  deeply  at 
the  side  of  the  right  iliac  fossa,  directly  opposite 
the  ileo-colic  valve,  and  at  an  acute  angle  with 
the  cascum.  Very  great  distension  of  the  caecum 
in  this  twisted  state  might  lead  to  obstruction, 
for  the  ascending  colon  appeared,  even  in  this 
case,  constricted  by  the  sudden  twist  and  by  the 
acute  angle  which  was  formed. 

No  symptom  had  apparently  been  pro- 
duced by  this  condition  of  the  caecum ;  but 
in  a  state  of  constipation,  when  the  caecum 
is  distended  with  feces,  considerable  impe- 
diment to  the  free  passage  would  be  the 
result.  It  is  probable  there  would  be  a 
greater  tendency  to  ulceration,  and  to  the 
passage  of  feces  into  the  appendix  caeci. 

CASE  CVI.  Intestinal  Obstruction  of  the 
Ascending  Colon.  The  Ccecum  twisted  to  the 

f  ,       -r     ~      T7.  j     TT  J.       J    •  Caecum   inverted,  appendix   to- 

left  side  into  the  Left  lhac  and  Hypochondriac  ^^  (he  pelvis  'whPere  it  was 
Regions.  Death  on  the  20th  day.  (Reported  adherent;  ascending  colon  com- 

by  Mr.  GaltOll.) Eliza  S ,  aet.  40,  a  COOk,  was      mencing  opposite  the  ileuni. 


326  ON    DISEASES    OF    THE    C.ECUM 

admitted  into  (iuy's  Hospital  under  the  care  of  Dr.  Addison,  November  Oth, 
],s .•)(•,.  SIM-  had  lived  regularly  and  temperately.  There  were  marks  of  dis- 
tension upon  tin-  abdomen,  but  she  stated  that  she  had  never  been  pregnant, 
but  that  when  a  child  her  abdomen  had  been  much  enlarged.  She  enjoyed 
good  health  until  she  was  fourteen  years  of  age,  when  she  fell  against  the 
rm-bstone  at  the  head  of  a  well,  whilst  she  was  drawing  water,  and  pain  in 
the  loins,  with  difficulty  in  micturition  and  hrematuria,  came  on.  Many 
\-eai>  he'ore  admission  she  had  jaundice,  with  great  ]  ain  in  the  stomach,  and 
was  told  she  had  inflammation  of  the  bowels  ;  she,  however,  had  good  health 
until  lS4f>,  when  during  frosty  weather,  she  fell  down  in  a  yard,  striking  her 
left  side  against  the  corner  of  a  stool ;  she  suffered  from  pain  and  tenderness 
at  the  part,  with  cold  chills  ;  the  urine  was  scanty,  but  no  blood  was  passed; 
a  lei-  remaining  in  bed  for  three  or  four  days  she  felt  no  further  inconvenience. 
The  bowels  had  been  frequently  confined  for  three  or  four  days  together,  but, 
without  any  pain  or  distress.  On  admission  into  Guy's  she  was  anu'inic,  but 
her  complexion  was  rather  dark;  three  days  previously,  without  apparent 
cause,  pains  came  on  in  the  right  side,  extending  to  the  umbilicus.  No  im- 
proper food  had  been  taken,  nor  was  there  any  stomach  derangement.  She 
felt  chilly;  the  bowels  had  been  open  previously,  and  again  very  slightly,  at 
the  time  of  admission.  There  had  been  no  vomiting  till  just  before  admis- 
sion, but  when  once  it  had  supervened  everything  was  rejected.  There  was 
no  tenderness  of  the  abdomen,  but  it  was  distended  with  flatus.  The  skin 
was  cool  and  moist,  the  urine  abundant,  pulse  80,  the  tongue  slightly  furred. 
A  soap  injection  was  administered,  and  ,$ss  of  castor-oil  given.  The  vomit- 
ing became  stercoraceous  and  then  lessened  in  severity,  but  the  pain  was 
aggravated. 

Various  measures  were  tried  for  her  relief;  all  were  of  no  avail,  nor  did 
they  succeed  in  even  modifying  the  symptoms  or  in  any  wray  aiding  the  for- 
mation of  a  diagnosis,  and  with  gradually  increasing  prostration  she  died  on 
the  27th,  about  twenty  days  after  the  commencement  of  the  symptoms. 

On  opening  the  abdomen  the  small  intestine  was  found  enormously  dis- 
tended, and  the  cnecum  was  situated  in  the  left  hypochondriac  region  and  iliac 
fossa,  forming  a  large,  greatly  distended,  almost  spherical  sac;  the  appendix 
was  situated  on  the  left  side.  The  whole  of  the  visceral  and  of  the  parietal 
peritoneum  was  intensely  injected,  and  was  covered  with  lymph.  The  right 
iliac  fossa  \vas  filled  by  coils  of  small  intestine,  the  peritoneum  being  perfectly 
smooth.  By  attempting  to  unravel  the  intestine,  and  tracing  the  large  intes- 
tine upward  from  the  sigmoid  flexure,  which  was  normally  situated  and  per- 
fectly collapsed,  a  stricture  was  found  about  the  middle  of  the  ascending 
colon  ;  the  stricture,  however,  was  situated  near  the  brim  of  the  pelvis  on  the 
left  side,  and  adhesion  of  the  omentum  was  found  at  this  part,  between  the 
ascending  colon,  sigmoid  flexure,  and  a  coil  of  ileum. 

The  line  of  obstruction  was  perfectly  defined,  all  the  intestine  below  being 
quite  empty,  collapsed,  and  non-injected.  The  obstruction  was  four  feet  four 
inches  from  the  anus,  and  appeared  to  have  been  produced  by  the  caecum 
revolving  on  the  termination  of  the  ileum,  which  was  fixed  by  its  adhesion 
to  the  sigmoid  flexure.  No  transverse  colon  could  be  found,  because  it  was 
hidden  behind  the  caecum  near  the  left  iliac  fossa.  On  removing  the  intestine 
the  stricture  .disappeared. 

The  mucous  membrane  of  the  caecum  wa*  intensely  injected,  and  a  patch 
on  the  interior  surface  was  of  a  leaden  color;  at  the  centre  of  this  part  was  a 
minute  slough,  and  perforation  extended  into  the  peritoneal  cavity;  but  no 
feral  extravasation  had  taken  place. 

The  mucous  membrane  of  the  ileum  was  healthy,  but  congested,  and  con- 


AND    APPEXD1X    C.EGI. 


327 


tained  both  solid  and  fluid  feces.  The  stomach  contained  fluid  fecal  matter 
such  us  was  found  in  the  ctecum.  The  duodenum  was  healthy,  and  the  liver' 
kidneys,  spleen,  &2.,  were  normal. 


Ctecum  inverted  and  twisied  on  its  own  axis  into  the  left  hypochondriac  region,  appendix  close  to 
the  spleen  ;  ascending  colon  constricted  ;  constriction  increased  by  band  of  adhesion  to  the  sigmoid 
flexure,  which  appeareJ  to  have  been  the  primary  cause  of  the  fatal  twist  and  obstruction. 

The  previous  attack  of  inflammation  of  the  bowels  had  probably 
led  to  the  adhesion  between  the  termination  of  the  ileum  and  the 
sigmoid  flexure;  and  this  was  one  of  the  causes  of  the  fatal  obstruc- 
tion. The  caecum  was  apparently  unnaturally  free,  and  its  disten- 
sion associated  with  this  adhesion  had  led  to  the  twisted  and  inverted 
position  which  was  found  after  death.  The  pain  had  commenced  at 
the  seat  of  the  disease,  near  the  right  iliac  fossa  -extending  to  the 
umbilicus.  The  patient  had  had  severe  falls  and  blows  upon  the 
abdomen,  one  in  particular,  in  which  she  struck  the  right  side,  and 
which,  perhaps,  tended  to  produce  displacement  or  inflammatory 
mischief.  The  bowels  had  generally  been  confined,  but  she  had 
occasionally  suffered  from  diarrhoea.  The  first  symptom  was  pain 
in  the  right  iliac  fossa,  and  then  constipation;  the  severe  colic,  dis- 
tension, tenderness,  and  vomiting  were  later  symptoms.  The  mode 


328  ON    DISEASES    OF    THE    CJBCUM 

of  commencement  appeared  to  indicate  that  they  did  not  arise  from 
simple  impacted  feces.  For  four  days  there  had  been  no  vomiting, 
which  showed  the  absence  of  internal  hernia,  of  sadden  strangula- 
tion, and  of  intussusception.  The  symptoms  were  neither  those  of 
enteritis  nor  of  acute  peritonitis. 

It  was  evident  that  there  had  been  some  chronic  changes  in  the 
intestines  or  peritoneum,  and  it  was  difficult  to  decide  the  character 
of  those  changes. 

No  tumor  could  be  felt;  but  there  were  three  causes  of  obstruc- 
tion left,  between  which  it  was  exceedingly  difficult  to  decide.  1. 
A  slow  growth  connected  with  the  intestine  itself,  as  cancer  or  one 
producing  chronic  contraction.  2.  Old  bands  of  adhesion;  and,  3, 
Twisted  intestine.  An  approximate  opinion  was  formed  as  to  the 
seat  of  obstruction ;  either  that  it  was  at  the  colon,  or  at  the  termi- 
nation of  the  ileum.  The  vomited  matters  were  so  fecal  in  their 
character  that  it  was  even  suggested  that  the  transverse  colon  might 
have  formed  a  communication  with  the  stomach. 

A  somewhat  similar  case  is  recorded  by  Sir  W.  Gull  in  the  'Guy's 
Hospital  Keports,'  1858,  p.  179. 

CASE  C VII.  Twisted  Caecum.  Obstruction.  Peritonitis — A  man,  jet. 
30,  was  admitted  into  Guy's  Hospital,  October  llth,  1859.  He  was  a  strong 
muscular  man,  and  for  three  weeks  his  bowels  had  acted  irregularly,  but  their 
precise  mode  of  action  could  not  be  ascertained.  On  October  9th  he  partook 
freely  of  pork,  ale,  &c.,  and  was  soon  afterwards  seized  with  intense  pain  in 
the  abdomen,  which  "doubled  him  up;"  vomiting  soon  afterwards  came  on; 
these  symptoms  continued,  and  excessive  prostration  followed.  The  bowels 
had  acted  on  Friday  the  7th,  but  not  afterwards  till  the  day  of  his  death. 
At  the  time  of  his  admission  into  Guy's,  on  the  evening  of  the  llth,  he  was 
cold,  almost  pulseless,  perfectly  sensible,  but  collapsed;  he  suffered  intense 
pain  in  the  abdomen;  the  abdomen  was  tympanitic,  and  presented  distension 
in  the  epigastric  region.  Opium  was  given:  an  enema  tube  was  introduced 
into  the  rectum,  but  only  passed  about  six  inches,  and  returned  smeared  with 
blood;  a  catheter  drew  off  no  urine  from  the  bladder.  Mr.  Stocker  thought 
that  the  introduction  of  an  acupuncture  needle  into  the  distended  part  might 
relieve  the  enormous  distension ;  several  punctures  were  made,  and  not  afford- 
ing relief,  a  minute  trocar  was  introduced,  much  flatus  passed,  and  a  small 
quantity  of  thin  feces ;  but  this  discharge  afforded  the  patient  much  relief. 

Tincture  of  opium  n\,xl,  chloroform  rt^x,  were  given  in  camphor  mixture. 
On  the  following  morning  he  still  lived,  cold,  almost  pulseless,  legs  drawn 
up;  abdomen  less  distended,  but  very  painful;  he  had  passed  water  during 
the  night;  he  stated  that  he  had  passed  flatus  several  times  from  the  bowels 
since  the  commencement  of  the  severe  symptoms.  About  11  o'clock  there 
was  an  evacuation  from  the  bowels,  but  the  state  of  collapse  continued,  and 
he  died  about  3  P.M. 

Inspection  on  the  13th,  nearly  twenty -four  hours  after  death — Decompo- 
sition was  commencing  in  the  abdomen,  which  was  still  much  distended. 
The  thoracic  viscera  were  quite  healthy.  On  opening  the  peritoneal  sac  the 
appendix  caeci  was  observed  about  the  centre  of  the  abdomen,  and  a  very 
large,  distended  cascum  occupied  the  greater  part  of  the  epigastric,  umbilical, 
and  left  hypochondriac  regions ;  a  distended  coil  of  ileum  and  a  portion  of 
ascending  colon  were  attached  to  its  inferior  part;  these  portions  were  all  of 
a  green  color,  and  evidently  strangulated.  The  rest  of  the  serous  membrane 


AND    APPENDIX    CJECI.  329 

was  much  injected,  reddish,  covered  with  a  thin  layer  of  adhesive  lymph  and 
smeared  with  red-colored,  opaque  serum.  The  small  intestines  were  dis- 
tended. On  passing  the  hand  beneath  the  strangulated  mass  the  constriction 
was  found  to  be  situated  near  the  right  iliac  fossa,  and  was  produced  by  the 
caecum  having  rotated  on  a  free  mesentery,  and  then  twisted  on  its  axis.  By 
turning  the  caecum  downwards  all  constriction  disappeared.  The  line  of 
strangulation  was  very  distinctly  marked  across  the  colon,  about  four  inches 
above  the  caecum,  and  rather  less  distinctly  across  the  ileum,  about  fifteen 
inches  from  the  valve.  The  mucous  membrane  of  the  whole  of  this  part  was 
intensely  injected,  in  some  parts  presenting  ecchymosis ;  it  very  readily 
separated,  and  was  covered  with  a  thin,  gray,  diphtheritic  layer;  there  was 
effusion  of  blood  also  into  the  constricted  mesentery.  The  intestine  in  this 
part  and  above  it  contained  fluid  feces,  but  some  half-digested  masses  of  food 
were  also  found  in  the  caecum.  The  stomach  was  healthy,  as  also  the  rest  of 
the  small  intestine ;  the  stomach  contained  green  fluid  almost  of  the  character 
of  that  in  the  small  intestine.  The  descending  colon  was  contracted,  and  in 
the  rectum  was  found  a  small  ulcer  immediately  above  the  sphincter.  The 
course  of  the  intestine  was  very  peculiar.  The  sigmoid  flexure  was  situated 
in  the  right  iliac  fossa,  the  left  being  perfectly  smooth  and  free  from  intes- 
tine ;  the  descending  colon  crossed  the  spine  in  the  centre  of  the  lumbar 
region,  from  the  inferior  part  of  the  spleen ;  the  transverse  colon  was  in  its 
ordinary  position,  but  had  the  enlarged  and  twisted  cseum  concealing  it;  the 
ascending  colon  had  a  curved  position  in  the  right  loin,  passing  from  the 
cascum,  which  was  situated  immediately  in  front  of  the  spine ;  and  at  the 
lower  part  of  its  curve  old  adhesions  existed  between  the  ascending  colon  and 
the  sigmoid  flexure,  situated  in  the  right  iliac  fossa.  The  left  kidney  was 
situated  at  the  brim  of  the  pelvis,  and  received  its  arterial  supply  from  the 
aorta  and  the  common  iliac  arteries ;  the  ureter  left  the  kidney  anteriorly. 
The  left  supra-renal  capsule  was  in  its  normal  position.  The  liver,  spleen, 
kidneys,  &c.,  were  healthy. 

The  caecum  in  this  case  was  preternaturally  free,  and  the  sigmoid 
flexure  in  the  right  instead  of  the  left  iliac  fossa.  It  is  probable 
that  several  weeks  before  death  the  caecum  had  a  twisted  position, 
and  that  after  an  indigestible  meal  flatulent  distension  increased  the 
twist,  and  rendered  the  obstruction  complete.  The  caecum  had  ap- 
parently turned  on  its  mesentery,  as  an  axis,  and  then  on  its  own 
axis.  The  adhesion  between  the  ascending  colon  and  sigmoid  flexure 
was  old,  and  possibly  formed  during  foetal  life.  The  position  of  the 
kidney,  partly  in  the  pelvis,  and  its  unusual  arterial  supply,  were 
evidence  of  congenital  malformation.  The  introduction  of  the  needle 
afforded  no  relief,  but  the  trocar  gave  immediate  cessation  of  pain, 
and  the  patient  begged  to  have  the  operation  repeated.  The  in- 
strument had  perforated  the  distended  caecum,  and  had  diminished 
the  distension  of  the  strangulated  part ;  it  was  left  in  the  wound,  so 
that  no  extravasation  took  place,  and  it  is  probable  that  this  relief 
to  the  distended  bowel  prolonged  the  patient's  life  several  hours, 
though  we  are  not  prepared  to  recommend  the  repetition  of  such  an 
operation  in  any  but  exceptional  cases. 

The  following  are  instances  of  a  form  of  caecal  disease  very  fre- 
quently met  with  ;  they  arise  from  distension  of  the  caecum,  which 
induces  local  enteritis,  with  partial  peritonitis;  the  latter  varies 
greatly  in  intensity,  being  sometimes  severe,  at  other  times  scarcely 


330  ON    DISEASES    OP    TIIE    CAECUM 

observable.  With  proper  care  and  judicious  treatment,  most  of  them 
recover.  The  symptoms  are  less  severe  than  those  in  which  the 
appendix  is  ulcerated,  or  contains  a  concretion  ;  they  come  on  more 
gradually,  the  pain  is  less  intense,  the  dulness  and  tenderness  are 
entirely  removed  as  the  inflammation  subsides,  and  the  bowel  is  freed 
from  its  contents.  As  in  cases  of  more  general  enteritis,  purgatives 
do  considerable  harm ;  they  fail  to  empty  the  distended  bowel,  they 
increase  the  enteritis,  lead  to  ulceration,  and  in  some  to  perforation 
and  fatal  peritonitis.  The  benefit  arising  from  the  action  of  the 
opium  is  very  marked — the  bowels  act,  the  pain  subsides,  and  the 
dulness  lessens  ;  mild  mercurials  with  the  opium  are  sometimes  used, 
but  we  prefer  opium  alone ;  abstinence  from  solid  food  and  absolute 
rest  are  very  important,  and  should  be  continued  for  several  days 
after  the  subsidence  of  the  pain.  If  the  pain  be  severe,  local  deple- 
tion by  leeches  affords  considerable  relief,  and  should  be  followed  by 
hot  fomentations. 

CASE  CVIII.  Ccecal  Distension  and  Inflammation.  Typhlitis — Crota 
"W — ,  a  strumous-looking  boy,  an  apprentice  to  a  cook  at  a  large  tavern,  after 
harder  work  than  usual,  was  seized  with  severe  pain  in  the  abdomen  on  the 
right  side  :  after  a  few  hours  this  partially  subsided,  but  again  returned  on 
his  making  exertion,  so  that  he  was  obliged  altogether  to  discontinue  his 
work.  The  bowels  were  occasionally  constipated. 

He  was  of  fair  complexion,  with  long  eyelashes,  and  his  countenance  had 
an  anxious  expression  ;  the  abdomen  was  hot,  tender  and  full,  especially  in 
the  region  of  the  caecum  ;  the  tongue  was  red,  the  pulse  soft,  the  thoracic 
viscera  normal ;  he  had  no  vomiting. 

Calomel  gr.  j,  opium  gr.  ss,  were  given  every  six  hours,  and  a  hot  poultice 
applied  to  the  abdomen.  Eight  leeches  were  afterwards  applied,  and  spare 
diet  allowed.  He  rapidly  improved,  and  in  a  few  days  was  convalescent. 
He  was  kept  in  bed,  however,  for  a  longer  period,  although  all  the  symptoms 
had  subsided. 

CASE  CIX.  Ccecitis  or  typhlitis — Benjamin  B — ,  get.  15,  a  pale,  thin  lad, 
who  had  been  employed  on  the  river,  was  admitted  into  Guy's  Hospital. 
January  14th,  18.02.  About  three  days  before  admission  he  had  experienced 
griping  pain  in  the  abdomen,  which  had  increased  in  severity.  The  bowels 
were  constipated,  but  there  was  no  vomiting,  nor  could  it  be  ascertained  that 
he  had  partaken  of  improper  diet.  There  was  fulness  of  the  right  iliac  region, 
with  dulness  and  considerable  tenderness.  Eight  leeches  were  applied,  and 
lie  took  calomel  and  opium  gr.  j  of  each  every  four  hours.  On  the  19th  the 
pain  had  considerably  diminished,  but  still  much  fulness  and  hardness  re- 
mained ;  there  was  no  febrile  disturbance  ;  the  tongue  was  clean  and  the 
pulse  natural.  The  calomel  and  opium  were  omitted. 

February  3.  He  felt  much  relieved,  but  hail  a  haggard  look  ;  the  eyes 
were  sunken,  and  occasional  pain  came  on  across  the  abdomen.  There  was 
no  marked  indication  of  progressive  disease,  and  the  fulness  in  the  iliac  region 
gradually  disappeared. 

23d.  There  was  again  very  perceptible  fulness  and  some  tumefaction  in 
the  right  iliac  region,  and  gurgling  on  pressure ;  slight  pain  had  returned  ? 
the  symptoms  were,  however,  very  much  less  severe  than  before,  and  he  was 
allowed  to  move  about  the  ward.  He  afterwards  lelt  the  hospital  convales- 
cent. 


AND    APPENDIX    C.ECI.  331 

The  symptoms  in  this  case  were  at  first  very  severe,  and  warranted 
a  very  cautious  prognosis.  .  They  were  probably  associated  with  a 
strumous  diathesis,  and  more  than  usual  disturbance  of  the  other 
abdominal  viscera.  There  is  much  fear  that  slow  strumous  dis- 
organization would  extend  in  this  case,  and  ultimately  lead  to  a  fatal 
result. 

The  permission  to  sit  up  led  probably  to  the  increase  of  the  symp- 
toms, but  happily  the  relapse  was  not  of  a  character  to  prevent  his 
convalescence.  This  was  an  instance  in  which  great  care,  nourishing 
diet,  and  change  of  air,  might  be  followed  by  complete  restoration  to 
health. 

CASK  CX.  Typhlitis — Sarah  A.  M — ,  aet.  20,  was  admitted  December 
27th,  1870,  into  Guy's  Hospital,  under  my  care.  Her  father  and  brother 
had  died  of  phthisis.  On  Wednesday , "December  20th,  whilst  doing  her  work 
MS  a  collar  dresser,  she  was  suddenly  seized  with  severe  pain  in  the  stomach, 
and  in  halt'  an  hour  the  pain  became  a  griping  character,  accompanied  by 
severe  sickness  and  purging.  She  went  home  to  bed.  and  hot  poultices  were 
applied;  the  purging  soon  subsided,  but  the  sickness  and  pain  continued  till 
admission.  The  abdomen  was  rather  tense,  and  she  suffered  from  severe  pain 
in  the  caecum,  where  an  enlargement  could  be  felt  about  the  size  of  a  cocoa- 
nut  ;  the  resonance  at  this  part  was  imperfect,  and  the  abdominal  muscles 
wen;  fixed.  The  tongue  was  moist,  but  had  a  whitish  fur;  there  was  thirst; 
no  appetite;  vomiting  came  on  if  food  was  taken;  the  pulse  was  130;  tem- 
perature 103°  ;  the  heart  and  lungs  were  healthy.  She  was  directed  to  re- 
main perfectly  quiet  in  bed,  and  gr.  j  of  opium  was  given  every  four  hours  ; 
poultices  were  applied  to  the  abdomen.  The  following  day  she  was  free  from 
pain,  and  there  was  scarcely  any  sickness.  The  pulse  was  108,  and  the 
temperature  98.8°.  On  January  1st  the  abdomen  was  less  tense  and  more 
resonant ;  the  patient  was  free  from  pain,  and  looked  more  cheerful  ;  there 
had  been  no  action  from  the  bowels;  temp.  97.8°;  pulse  100.  The  same 
treatment  of  perfect  rest,  with  opium  less  frequently  administered,  was  con- 
tinued. On  January  6th,  ten  days  after  admission,  as  she  complained  of 
forcing  pain  in  the  rectum,  a  simple  enema  was  used,  which  relieved  the 
bowels.  Fish  was  now  allowed,  and  the  opium  given  night  and  morning. 
The  fulness  in  the  caecum  had  considerably  lessened.  On  January  13th  the 
bowels  acted  twice  without  any  enema;  the  patient  expressed  herself  as  well. 
The  opium  was  discontinued.  A  little  thickening  in  the  caecal  region  could 
be  felt  on  deep  pressure,  but  it  disappeared  before  she  left  the  hospital  well 
on  the  23d. 

CASE  CXI.  Ccecal  Inflammation  simulating  Hip  joint  Disease — James 
C — ,  jet.  11,  living  at  Gravesend,  was  admitted  into  Guy's  Hospital,  under 
my  care,  February  18th,  '1857.  He  was  a  strumous  child,  but  he  was  stated 
to  have  had  good  health  until  three  months  before  admission.  He  was  roughly 
used  and  beaten  whilst  at  work  ;  and  he  did  not  feel  well  afterwards ;  pain 
came  on  in  the  abdomen  ;  but  it  did  not  become  severe  till  a  short  time  before 
admission,  when  his  foot  slipped,  and  his  abdominal  muscles  were  brought 
into  powerful  action.  Severe  pain  in  the  region  of  the  crccum  then  came  on, 
and  was  much  aggravated  by  pressure  ;  the  rest  of  the  abdomen  was  soft ; 
the  tongue  was  clean  ;  pulse  75.  The  bowels  were  confined,  and  the  urine 
was  normal.  The  right  leg  was  flexed  at  the  thigh,  and  could  not  be  straight- 
ened ;  rotation  of  the  hip,  striking  the  heel,  &c.,  did  not  produce  pain,  nor 


332  ON    DISEASES    OF    THE    C.ECUM 

was  there  any  pain  in  the  knee  or  in  the  spine.  Seven  leeches  were  applied 
to  the  right  illiac  fossa ;  gray  powder  gr.  iij,  Dover's  powder  gr.  iij  were 
ordered  three  times  a  day,  with  rest  and  low  diet. 

The  leeches  and  hot  poultice  afforded  much  relief;  he  was  able 
then  partially  to  straighten  the  hip,  which  had  evidently  been  drawn 
up  to  relieve  the  pain,  by  relaxing  the'  flexor  muscles  of  the  joint. 
The  bowels  on  the  second  day  acted  by  soap  injection,  and  on  the 
third  day  the  leg  was  straight.  The  pain  and  fulness  gradually 
ceased ;  he  was,  however,  kept  in  bed ;  the  medicine  was  continued 
once  a  dav  for  a  short  time,  and  animal  food  was  allowed  very  spar- 
ingly. The  bowels  acted  without  trouble.  On  March  2d  he  was 
convalescent ;  cod-liver  oil  was  given  three  times  a  day,  and  on  the 
13th  he  left  the  hospital  well. 

CASE  CXII.  Ceecal  Disease.  Typhlitis.  Recovery.  (Reported  by  Mr. 
Brietzcke.) — James  B — ,  aet.  23,  a  draper's  assistant,  residing  in  the  Bor- 
ough, was  admitted  under  my  care  into  Guy's  Hospital,  Novembr  2d,  l.sill. 
Whilst  sitting  at  breakfast,  on  the  31st  of  October,  he  was  suddenly  seized 
with  severe  pain  on  the  right  side  below  the  ribs;  the  severity  of  the  pain 
bent  him  double,  and  rendered  him  almost  insensible;  medical  advice  was 
at  once  sought,  and  medicine  given  every  two  or  three  hours,  which  how- 
ever, produced  vomiting  whenever  it  was  taken.  On  the  1st  November  he 
was  partially  relieved,  but  was  worse  again  in  the  evening.  On  the  2d  he 
was  brought  to  the  hospital ;  the  pain,  which  had  subsided,  again  returned 
severely,  and  was  accompanied  with  an  urgent  but  ineffectual  desire  to  pass 
water.  The  bowels  were  acted  upon  once  daily  till  the  31st  October,  but  no 
evacuation  was  again  passed  till  after  admission.  He  had  a  pale  and  anxious 
expression  of  countenance ;  he  had  lost  his  appetite,  and,  since  the  attack, 
had  been  deprived  of  sleep.  In  the  right  iliac  region  there  was  defined 
hardness,  imperfect  resonance,  and  great  tenderness  on  pressure  ;  but  the 
abdomen  generally  was  neither  distended  nor  tender.  There  was  pain  on 
passing  water,  and  only  a  small  quantity  was  discharged.  The  tongue  was 
furred,  and  the  mouth  and  throat  were  dry.  The  pulse  was  04,  and  com- 
pressible. There  was  no  pain  produced  by  respiration  ;  the  urine  contained 
a  small  quantity  of  sugar.  He  was  ordered,  of  soap  and  opium  pill  gr  v 
night  and  morning,  and  to  have  an  injection  of  castor  oil,  and  a  diet  of  beef 
tea  and  arrowroot. 

This  treatment  was  continued,  and  the  bowels  acted,  no  vomiting  was  pro- 
duced, and  the  tenderness  in  the  caecal  region  subsided,  and  on  the  7th  both 
pain  and  swelling  had  disappeared.  The  bowels  on  that  day  acted  regularly, 
pulse  GO,  tongue  clean,  and  there  was  no  difficulty  in  passing  water.  Infu- 
sion of  cusparia  3j  was  given  twice  a  day.  On  the  llth  he  left  the  hospital 
quite  well. 

In  this  case  the  symptoms  of  cascal  disease  were  well  marked ; 
there  was  severe  pain,  with  hardness  and  swelling  in  the  region  of 
the  caecum,  and  obstinate  constipation;  vomiting  had  apparently 
been  produced  by  attempts  to  obtain  action  from  the  bowels ;  but  by 
the  continued  use  of  opium,  with  bland,  demulcent  diet  and  a  castor 
oil  injection,  the  severe  pain  subsided,  the  tenderness  ceased,  and  the 
bowels  acted  naturally.  No  mercurial  was  given,  nor  did  it  seem 
necessary,  for  the  bowels  would  not  have  acted  more  readily  if  mer- 


AND    APPENDIX    C&CI.  333 

cury  had  been  conjoined  with  the  opium,  and  the  convalescence 
would  probably  have  been  less  rapid. 

CASE  CXIIL— The  following  is  of  great  interest  as  showing  a  state 
of  strumous  inflammation  of  the  caecum,  in  itself  probably  not  of  a 
fatal  character,  and  allied  to,-  if  not  identical  with  those  previously 
detailed,  but  rendered  fatal  by  its  association  with  phthisis. 

Ann  C — ,  aet.  46,  was  admitted  into  Guy's  Hospital  under  my  care  Feb- 
ruary 28th,  1855,  and  died  March  30th.  She  was  a  married  woman,  who 
had  resided  in  Southwark,  and  in  her  employment  as  a  milk  woman  had  been 
much  exposed  to  the  weather.  Some  of  her  family  had  died  from  phthisis. 
For  several  years  she  had  been  subject  to  cough,  which  had  become  more 
severe  during  the  last  eighteen  months.  She  was  thin  and  haggard,  the  face 
was  slightly  congested,  and  the  physical  signs  were  those  of  general  bron- 
chitis with  phthisis.  The  pulse  was  irregular  and  intermittent,  and  there 
was  a  systolic  bruit  below  the  nipple.  The  bronchitis  was  slightly  relieved, 
and  then  the  signs  of  disorganization  of  the  lung  became  more  marked. 
Three  days  before  death  severe  pain  came  on  in  the  right  side,  accompanied 
with  increased  dyspnoea.  Some  irritation  of  the  bowels  supervened,  but  not 
to  a  great  extent,  and  she  gradually  sank. 

On  inspection  the  abdomen  was  distended  and  tympanitic.  The  larynx 
was  healthy ;  the  bronchi  were  much  dilated  ;  this  bronchial  dilatation  was 
very  marked  on  the  right  side,  and  on  section  the  dilated  tubes  covered  a 
considerable  portion  of  the  surface.  Their  mucous  membrane  was  much  con- 
gested, and  covered  with  tenacious  mucus  ;  they  were  surrounded  by  crepi- 
tant  lung.  The  bronchi  on  the  left  side  were  much  less  dilated.  The  left 
pleura  was  universally  adherent,  but  the  right  only  so  at  its  apex ;  at  the 
right  base  the  pleura  was  covered  with  lymph,  and  the  cavity  contained 
about  a  pint  of  pus ;  a  small  vomica  immediately  beneath  the  pleura  had 
opened  into  the  pleural  sac.  There  was  a  large,  irregular  vomica  at  the  left 
apex,  and  in  the  lower  lobe  were  other  smaller  ones,  and  numerous  miliary 

tubercles.     The  heart  was  healthy.     Abdomen There  were  old  adhesions 

generally  in  the  peritoneum,  and  several  adherent  cretaceous  deposits.  The 
ceecum  was  inflamed,  and  presented  raised  patches  about  the  size  of  peas, 
soft,  situated  in  the  mucous  membrane  and  containing  pus ;  some  of  these 
collections  of  tuberculo-inflammatory  product  had  given  way,  and  slight  ulcer- 
ation  was  the  result.  The  ascending  colon  was  in  a  similar  condition.  The 
appendix  caeci  and  the  other  portions  of  the  intestine  were  healthy.  The 
liver  was  fatty,  the  kidneys  healthy,  so  also  were  the  mesenteric  glands. 

This  case  might  be  considered  as  one  of  chronic  bronchitis,  and 
afterwards  of  phthisical  disorganization.  In  the  caecum  it  is  pro- 
bable that  the  solitary  glands  became  diseased,  and  degeneration 
of  tubercle  led  to  the  production  of  minute  abscesses  and  ulceration. 

CASE  CXIV.  Perforation  of  the  Ccecum.    Abscess  extending  to  the  Groin. 

Phthisis Michael  R — ,  aet.  34,  was  admitted   into  Guy's  Hospital  under 

Mr.  Key's  care,  in  September,  1835 ;  he  was  a  temperate  man,  but  of  stru- 
mous habit,  and  by  trade  a  compositor.  For  a  year  and  a  half  he  had  been 
subject  to  flatulence,  indigestion,  and  occasional  purging.  Four  days  before 
admission,  after  four  days  of  diarrhoea,  he  had  experienced  sudden  pain  in 
the  right  iliac  fossa,  where  was  a  firm  swelling,  with  persistent  pain  ;  the 
bowels  were  variable ;  the  constitutional  disturbance  was  slight ;  the  pulse 


334  ON    DISEASES    OF    THE    CAECUM 

was  soft  and  quickened,  and  the  tongue  was  slightly  furred.  Leeches  were 
applied,  and  antimony  was  administered ;  suppuration  and  fluctuation  became 
nion-  manifest  in  the  tumor,  and  hectic  supervened.  Six  weeks  after  admis- 
sion an  opening  was  made  and  jjviij  of  offensive  pus  evacuated;  .-ymptoms 
of  phthisis  gradually  developed  themselves,  and  the  patient  died  in  the  follow- 
ing June.  Two  openings  existed  above  the  right  groin  ;  they  communicated 
with  a  contracted  space,  which  was  surrounded  by  dense  membrane.  The 
caecum  was  found  bound  down  by  firm  cellular  adhesions  to  the  neighborhood 
of  Foil  part's  ligament.  The  appendix  was  thick,  opaque,  and  filled  with  a 
pasty  fluid,  and  communicated  with  the  caecum.  A  sinuous  canal  of  one  and 
a  half  inches  in  length,  narrow  and  apparently  closing,  led  from  the  opening 
on  the  surface  into  the  caecum  at  its  posterior  part,  nearly  opposite  to  the 
opening  of  the  ileum.  The  coats  of  the  intestine  were  thickened,  but  the 
mucous  membrane  did  not  appear  to  be  changed,  except  that  a  few  contrac- 
tions from  cicatrices  were  evident.  (Prep,  in  Museum,  187D'0.) 

In  this  case  the  patient  survived  the  immediate  effects  of  the 
coecal  disease;  the  perforation,  instead  of  setting  up  inflammation  in 
the  peritoneum,  produced  suppuration  in.  the  cellular  tissue  of  the 
iliac  fossa,  and  the  pus  was  discharged  near  the  anterior  and  supe- 
rior spinous  process.  If  there  had  been  any  cicatrices  in  the  caecum, 
we  should  have  questioned  whether  the  disease  had  not  commenced 
in  the  iliac  fossa,  and  afterwards  extended  into  the  'caecum,  as  we 
have  found  to  occur  in  connection  with  the  sigmoid  flexure.  The 
commencement  resembled  that  of  ordinary  csecal  disease  ;  but  in  its 
progress  it  might  easily  have  been  mistaken  for  abscess  in  the 
parietes  of  the  abdomen. 

Disease  of  the  appendix  sometimes  exists  without  manifesting  any 
symptom ;  this  is  especially  the  case  in  phthisis.  The  appendix 
often  presents  strumous  deposit  in  larger  or  smaller  masses ;  it  is 
often  filled  with  feces;  and  not  unfrequently  we  find  it  distended 
with  thin  pus,  with  occlusion  of  the  orifice,  or  with  ulceration,  with- 
out any  pain  or  tenderness  having  been  complained  of,  as  in  the 
following  instance : — 

CASE  CXV.  Tuberculosis.  Ulceration  of  the  Intestine.  Ulceration  of 
the  Ca>.cum.  Perforation.  Abscess  behind  the  Ascending  Colon.  Old  Hy- 
datid  in  the  Liver.  (Reported  by  Mr.  H.  A.  Latimer.) — Thomas  A.  T — , 
aet.  54,  was  admitted  under  my  care  on  April  4th,  1871.  He  had  resided  at 
Hackney;  and  been  employed  as  a  tea  warehouse  man.  lie  had  formerly 
drank  freely  of  beer,  but  he  became  a  teetotaler  in  1855.  Till  three  years 
ago  his  general  health  had  been  good,  but  lie  then  had  an  attack  of  pleurisy 
on  the  left  side  ;  he  was  ill  for  two  or  three  months,  but  afterwards  went  to 
work,  and  continued  at  his  employment  till  twelve  weeks  before  admiss'on. 
For  at  least  twelve  months  he  had  been  complaining  of  pain  in  the  right  si.le 
at  the  region  of  the  liver,  and  he  had  been  unable  to  hold  himself  upright  in 
consequence  of  the  pain. 

"W  hen  quite  young  he  had  a  fall  from  a  horse,  and  antero-posterior  spinal 
curvature  in  the  dorsal  region  was  produced.  He  had  also  suffered  from 
double  hernia,  for  which  he  had  worn  a  truss.  Some  weeks  before  he  was 
seized  with  more  severe  pain  on  the  right  side,  and  there  was  enlargement  in 
the  region  of  the  right  hypochondrium.  The  practitioner  in  attendance  re- 
garded the  disease  as  hematic  abscess,  and  this  opinion  was  confirmed  by  the 


AXD    APPENDIX    CJECI.  335 

discharge  of  pus  from  the  bowel,  and  the  subsidence  of  the  swelling.  On  April 
2d  vomiting  and  purging  came  on,  and  continued  till  admission  on  the  4th. 
He  had  emaciated  rapidly  before  being  brought  to  the  hospital.  He  was 
then  pale  and  anaemic ;  he  was  free  from  pain  when  perfectly  quiet,  but  pain 
came  on  when  he  was  moved ;  it  was  located  in  the  right  hypochondrium. 
He  was  very  sick,  and  vomited  almost  every  ten  minutes,  all  food  being  at 
once  rejected.  He  complained  of  faintness.  The  left  leg  was  enormously 
swollen  and  distended,  the  veins  were  iruich  enlarged,  and  there  were  some 
petechial  blotches  below  the  knee.  The  leg  began  to  swell  on  April  2d,  and 
attained  its  great  si/e  in  an  hour  and  a  half.  It  was  very  painful  when  touched 
or  moved.  The  right  leg  was  of  natural  size  and  free  from  pain.  On  pres- 
sure in  the  right  hypochondrium  a  distinct  nodular  hardness  could  be  felt,  and 
there  was  fulness  and  tenderness  extending  to  the  iliac  region  ;  the  rectus 
was  rigid.  The  tongue  had  a  yellowish  fur  upon  it ;  the  pulse  was  126,  very 
small  and  feeble.  The  heart  and  lungs  did  not  present  any  signs  of  disease. 
The  urine  had  a  sp.  gr.  of  1016,  and  was  very  albuminous. 

The  left  leg  was  wrapped  in  cotton-wool  and  a  cradle  was  placed  over  it. 
Brandy  was  allowed.  When  admitted  the  patient  seemed  almost  in  a  dying 
state.  The  vomiting,  however,  ceased,  and  he  rallied.  On  the  8th  the  tem- 
perature was  97.4°,  the  pulse  103  ;  he  felt  stronger  and  more  comfortable, 
and  there  was  freedom  from  sickness.  There  was  still  much  uneasiness  on 
the  right  side.  The  sedative  mixture  of  bismuth  (Guy's)  was  ordered. 

On  the  15th  opium  and  belladonna  were  given  to  relieve  pain  and  sickness, 
which  again  distressed  him,  and  relief  was  thus  afforded  to  those  symptoms. 

On  the  25th  he  complained  of  great  weakness.  A  rounded  swelling  of 
great  density  could  be  felt  in  the  liver;  the  mouth  was  aphthous  and  ulcer- 
ated. Borax  and  honey  were  ordered. 

On  the  26th  the  left  leg  had  nearly  regained  its  natural  size.  The  right 
leg,  however,  became  suddenly  swollen  as  the  left  had  been,  and  the  patient 
soon  sank,  but  was  sensible  till  nearly  the  close. 

Inspection  was  made  on  the  27th.  There  were  extensive  old  pleuritic 
adhesions ;  the  lungs  contained  an  excess  of  fibrous  tissue ;  there  were  nu- 
merous scattered  tubercles,  and  a  few  small  cavities  filled  with  pus.  The 
heart  was  healthy,  so  was  also  the  stomach.  There  were  numerous  tubercular 
ulcers  scattered  through  the  ileum.  These  were  most  frequent  and  largest 
near  to  the  caecum  ;  and  there  was  tubercular  deposit  on  the  peritoneal  sur- 
face of  the  intestine  beneath  the  ulcers.  The  appendix  caeci  was  healthy,  but 
the  caecum  was  perforated  by  ulceration  close  to  its  base.  The  perforation 
opened  into  a  fecal  abscess,  which  extended  behind  the  colon  upwards  to  the 
under  side  of  the  liver.  There  had  been  chronic  peritonitis,  and  the  colon 
had  become  glued  to  the  peritoneal  walls.  In  the  liver,  which  was  rather 
fatty,  there  were  two  old  hydatid  cysts  filled  with  calcareous  substance.  One 
of  these,  about  the  size  of  a  small  hen's  egg,  was  superficial,  and  had  been 
felt  during  life.  The  mesenteric  glands  were  much  enlarged,  but  did  not 
contain  any  cancerous  product.  Booklets  of  the  echinococcus  were  detected 
in  the  fluid  from  the  cysts.  The  spleen  was  healthy  ;  the  kidneys  were  fatty, 
rather  large,  and  their  cortex  was  wasted.  The  femoral  veins  were  obstructed 
by  old  fibrinous  clots. 

The  diagnosis  of  this  case  was  obscure;  the  history  was  that  of  in- 
flammatory disease  in  the  neighborhood  of  the  ascending  colon,  but 
the  emaciated  and  cachectic  appearance  of  the  patient  and  the  pres- 
ence of  a  hard  nodule  in  the  liver,  favored  the  idea  of  malignant  dis- 
ease ;  the  enlargement  of  the  legs  evidently  arose  from  venous  ob- 


336  ON    DISEASES    OF    THE    CAECUM 

struction.  When  brought  to  the  hospital  it  was  believed  that  he 
could  not  survive  many  hours,  and  he  was  too  ill  to  be  raised  from 
a  recumbent  position  or  for  the  chest  to  be  examined  posteriorly. 
He  was,  however,  free  from  cough  or  symptoms  of  thoracic  disease. 
The  post-mortem  examination  fully  explained  the  nature  of  the  case; 
tubercular  ulceration  of  the  small  intestine  and  of  the  cascum  had 
been  followed  by  perforation  of  the  latter;  a  post- peritoneal  abscess 
was  formed,  which  extended  to  the  under  surface  of  the  liver;  the 
distension  of  this  abscess  with  pus  and  fecesled  to  the  swelling  below 
the  liver;  and  the  discharge  of  pus  from  the  bowel  appeared  to 
confirm  the  supposition  of  abscess  in  the  liver.  Local  peritonitis 
and  adhesion  had  taken  place,  fixing  the  colon  to  the  liver  and  pre- 
venting the  extension  of  the  disease.  The  exhaustion  consequent 
on  this  fecal  abscess  was  the  cause  of  death.  Tubercles  were  present 
in  the  lungs,  and  small  vomicae  were  found  filled  with  pus,  but  the  latter 
would  not  have  afforded  any  physical  sign  whilst  filled  with  fluid 
secretion.  The  enlargement  of  the  mesenteric  glands  was  tubercular. 
The  malady  was  one  of  phthisical  disease  affecting  especially  the 
intestine,  leading  to  perforation,  and  causing  death  before  the  pulmo- 
nary disease  had  made  extensive  progress.  The  hydatid  cysts  were 
very  old,  and  the  calcareous  envelope  prevented  the  detection  of  fluc- 
tuation ;  they  were  mere  coincidental  conditions,  but  they  tended  to 
render  the  diagnosis  obscure. 

CASE  CXVI.     Inflammation  of  the   Colon  from  Plum-stones.     Ulcera- 
tion.   Perforation.    Peritoneal  Abscess.    Thickening  and  Contraction  of  the 

Bowel (Reported  by  Mr.  F.  C.  Coley.) — Charles  G — ,  set.  49,  was  a  married 

man,  who  had  resided  at  Kensington,  of  temperate  habits  and  healthy,  with 
the  exception  of  attacks  of  indigestion.  Some  years  before  he  had  resided  in 
the  country,  and  had  much  anxiety  in  his  business ;  he  then  came  to  London 
and  became  a  warehouseman.  His  long  hours  of  work  led  to  exhaustion  ;  lie 
lost  his  appetite,  was  unable  to  digest  his  food,  and  he  occasionally  suffered 
from  rigors  at  night.  Two  years  before  admission  his  work  was  lessened  by 
his  removal  into  the  counting-house,  and  his  symptoms  were  relieved.  About 
three  weeks  before  admission  into  Guy's  Hospital,  on  September  23d,  1874, 
the  indigestion  increased,  and  the  patient  suffered  from  pain  in  the  right 
lumbar  and  inguinal  regions.  He  was  a  well-built  man,  rather  thin  and  sal- 
low, with  a  care-worn  expression  of  countenance.  He  complained  of  pain  in 
the  right  side  of  the  abdomen  below  the  liver,  and  a  lobulated  swelling  could 
be  detected  at  this  part,  which  was  with  difficulty  separated  from  the  liver. 
It  extended  partly  into  the  loin,  and  was  moderately  tender  on  palpation  ; 
the  dulness  in  the  swelling  was  not  complete.  The  lungs  and  heart  were 
normal.  The  tongue  was  white  and  marked  with  the  teeth.  Urine  healthy. 
He  was  ordered  the  bismuth  mixture,  and  allowed  fish  and  giv  of  wine.  The 
bowels  acted  by  medicine ;  the  motion  was  pale  and  fluid,  and  free  from 
blood.  It  was  found  after  admission  that  taking  food  increased  the  pain  in 
the  right  side.  The  mucous  membrane  of  the  lower  lip  was  raised  on  its 
inner  side  by  extravasated  blood,  but  there  was  no  breach  of  surface.  The 
swelling  gave  pain  during  mastication.  On  the  29th  the  motion  was  olive- 
green  in  color  and  free  from  blood  ;  the  pain  in  the  abdomen  was  less.  The 
temperature  was  taken  many  times,  and  varied  from  98°  to  99.4°.  The 


AND    APPENDIX    C^CI.  337 

bowels  became  constipated,  and  a  small  quantity  of  blood  was  passed.  Full 
injections  of  water — 2  to  4  pints — brought  away  hardened  feces ;  they  were 
repeated  on  successive  days,  and  carbonate  of  ammonia  mixture  given  instead 
of  the  bismuth.  On  October  22d  the  swelling  was  smaller,  but  still  tender 
and  painful;  it  could  be  separated  from  the  liver,  and  appeared  to  be  adherent 
to  the  abdominal  walls.  The  castor-oil  mixture  was  given,  and  acted  gently 
but  freely  on  the  bowels.  Iodine  was  applied  externally.  The  swelling  re- 
mained tender,  but  the  patient  gained  strength,  and  wished  to  return  home, 
which  he  did  on  November  30th.  On  December  28th  I  saw  him  at  his  own 
home  in  consultation  with  Dr.  Cortis.  The  patient  appeared  thin  and  ema- 
ciated ;  he  had  lost  strength,  and  the  bowels  acted  sluggishly ;  the  hardness 
on  the  right  side  was  as  distinct  as  when  he  left  the  hospital ;  the  pulse  was 
very  compressible,  and  the  appetite  poor.  He  sank  more  quickly  than  we 
expected,  and  he  died  on  January  3d. 

Dr.  Cortis  made  a  post-mortem  examination,  and  was  kind  enough  to  send 
me  the  following  report  :  "  On  opening  the  abdomen  a  large  portion  of  the 
liver  was  found  very  firmly  adherent  to  the  walls.  Between  the  two  at  one 
part  was  found  a  circumscribed  cavity  containing  four  plum-stones  and  the 
kernel  of  a  fifth.  Tins  cavity  communicated  by  a  small  opening  with  the 
colon,  which,  beyond  the  cavity,  was  very  much  thickened  and  contracted, 
forming  a  stricture,  through  which  an  ordinary  holder  of  a  steel  pen  could 
just  pass.  The  stones  had  evidently,  years  ago,  lodged  in  the  colon,  produced 
inflammation  and  perforation  (after  adhesion),  and  afterwards  kept  up  the 
irritation  and  consequently  the  inflammation  round  the  gut,  producing  the 
deposit  and  causing  the  stricture.  The  caecum  was  firmly  adherent  at  the 
under  surface  of  the  liver,  and  the  perforation  was  at  the  anterior  and  external 
portion." 

In  this  case  the  diagnosis  was  obscure ;  there  was  evidently  disease 
of  the  ascending  colon  and  caecum,  but  the  hardness  was  at  first 
separated  with  difficulty  from  the  liver ;  this  separation  could,  how- 
ever, be  well  made  out  afterwards  when  the  bowel  was  emptied  by 
enemata,  &c.  It  was  more  difficult  to  diagnose  the  nature  of  the 
malady  than  to  recognize  its  position.  There  was  hindrance  to  the 
free  action  of  the  bowel,  and  blood  with  mucus  was  passed.  These 
signs  indicated  some  ulceration  with  narrowing  of  the  bowel.  The 
onset  of  pain  about  four  hours  after  food  also  indicated  disease  of 
the  larger  bowel.  The  mischief  had  come  on  gradually,  and  without 
any  history  of  febrile  disturbance  such  as  we  generally  find  in  acute 
disease  of  the  caecum ;  it  was  irregular  and  nodular  in  character, 
hard  and  tender,  and  resembling  in  these  respects  malignant  disease. 
We  certainly  did  not  suspect  that  there  was  such  a  source  of  irrita- 
tion as  a  peritoneal  abscess  containing  plum-stones.  It  would  seem 
that  inflammation  of  the  mucous  membrane  had  been  followed  by 
ulceration  and  perforation;  peritoneal  adhesion  had  localized  the 
effusion ;  the  presence  of  the  foreign  bodies  in  the  peritoneum  led 
to  gradual  thickening  of  the  coats  of  the  bowel  and  to  obstruction. 
The  obstruction  increased,  but  the  exhaustion  of  strength  kept  pace 
with  the  narrowing  of  the  bowel,  and  the  patient  sank  from  exhaus- 
tion rather  than  from  intestinal  obstruction.  The  perforation  in  the 
first  case  was  in  the  posterior  part  of  the  caecum,  and  the  abscess 
burrowed  upwards  behind  the  intestine ;  in  this,  it  was  at  the  ante- 
22 


338  ON    DISEASES    OF    THE    C.ECUM 

rior  part  of  the  ascending  colon,  not  far  from  the  angle  of  the  trans- 
verse colon  and  near  to  the  liver. 

CASE  CXVII.  Phthisis.  Ulceration  of  the  Larynx  and  of  the  Jleum. 
Concretion  in  the  Appendix — Thomas  E — ,  aet.  18,  a  delicate,  strumous  lad, 
was  admitted  with  phthisis  on  February  27th,  and  died  May  4th.  On  inspec- 
tion, eighteen  hours  after  death,  the  lungs  were  found  to  contain  caseous  and 
pneumonic  deposit,  old  gray  induration,  and  a  large  vomica  at  the  left  apex. 
The  larynx  was  deeply  ulcerated  at  the  inferior  vocal  cords.  The  ileum  con- 
tained in  its  mucous  membrane  strumous  deposit,  and  a  large  ulcer  existed 
at  the  valve ;  the  appendix  contained  a  waxy  concretion,  white  lamellated, 
about  an  inch  long,  and  placed  at  its  extremity  ;  the  remainder  of  its  canal 
was  filled  with  mucus.  This  concretion  appeared  to  be  composed  of  inspis- 
sated mucus. 

In  another  case  of  phthisis  we  found  that  an  ulcerated  appendix 
caeci  opened  into  the  ileum. 

CASE  CX VIII — Pyaemia.  Necrosed  Humerus.  Ccecal  Disease — Wm. 
S — ,  aet.  72,  was  admitted  into  the  hospital  January  30th,  and  died  February 
16th,  1856.  He  had  received  six  months  before  death  a  compound  fracture 
of  the  left  humerus,  and  Mr.  Birkett  had  removed  a  portion  of  the  resulting 
necrosed  bone  ;  the  wound  did  not  heal,  and 'the  patient  became  increasingly 
prostrate ;  nine  days  before  death  he  suffered  from  pain  in  the  abdomen. 

Inspection  was  made  forty  hours  after  death.  The  body  was  much  de- 
composed :  the  lungs,  liver,  and  kidneys  were  too  much  changed  to  decide  ns 
to  the  existence  of  acute  disease.  There  was  considerable  development  of 
fat ;  the  peritoneum  was  greasy,  and  in  the  right  caecal  region  several  coats 
of  intestine  were  adherent ;  on  removing  them  about  a  cupful  of  pus  was 
poured  out;  this  was  found  to  arise  from  the  neighborhood  of  the  appendix 
caeci.  The  appendix  contained  several  small,  circular  ulcers,  and  one  of  these 
had  a  pinhole  opening  into  the  peritoneal  cavity.  The  whole  of  its  parietes 
were  much  thickened,  especially  at  the  extremity,  which  was  white  and 
fibrous ;  the  appendix  contained  pus.  The  caecum  itself,  the  ileum,  and  the 
rest  of  the  intestines  were  healthy.  There  were  no  tubercles,  nor  evidence 
of  phthisical  disease  in  the  lungs.  The  right  shoulder-joint,  the  sterno- 
clavicular  articulation,  &c.,  were  filled  with  pus.  On  the  left  side  was  an 
oblique,  ununited  fracture  of  the  humerus. 

It  is  very  unusual  to  find  a  patient  at  seventy-two  years  of  age  the 
subject  of  coecal  disease ;  neither  did  it  appear  to  be  the  direct  cause 
of  death ;  the  man  died  from  pyaemia,  consequent  on  necrosed  bone. 
Cases,  however,  may  arise  of  pyaemia  produced  by  caecal  disease  alone; 
the  probability  is,  that  in  a  poisoned  condition  of  the  blood,  slight 
irritation  at  the  caecum  had  been  followed  by  ulceration,  perforation, 
and  subsequent  suppuration. 

CASE  CXIX — Disease  of  the  Caecum  following  a  Blow.  Perforation  of 
the  Appendix.  Suppuration.  General  Peritonitis.  Almost  complete 
secondary  Perforation  of  the  Gcecum — Christopher  B — ,  set.  21,  was  ad- 
mitted into  Guy's  Hospital,  in  a  dying  state,  June  1st,  1859,  and  expired  a 
few  hours  afterwards.  Two  years  previously  he  had  received  a  severe  blow 
in  the  region  of  the  caecum,  but  it  was  a  week  before  admission  that  sudden 
pain  came  on  in  the  abdomen.  On  inspection  the  abdominal  serous  mem- 
brane was  found  to  be  intensely  injected  and  acutely  inflamed.  On  separat- 


AND    APPENDIX    CJ3CI.  339 

ing  the  last  coil  of  the  small  intestine  from  the  caecum,  a  small  abscess  was 
observed,  which  communicated  with  the  appendix  caeci  ;  nearly  the  whole 
side  of  the  appendix  was  destroyed  by  ulceration,  and  the  pus  had  separated 
the  coats  of  the  intestine  as  far  as  the  caecum,  with  which  it  was  on  the  point 
of  forming  a  second  opening.  The  mucous  membrane  of  the  rest  of  the  in- 
testine, and  the  other  viscera,  were  healthy. 

The  blow  had  probably  in  this  instance  set  up  caecal  disease,  which 
manifested  but  slight  symptoms  till  perforation  took  place  a  week 
before  his  death.  Suppuration  followed,  and  was  localized  by  adhe- 
sions; but,  most  unwisely,  he  was  taken  from  his  bed,  and  shaken  in 
his  transit  to  the  hospital,  which  he  reached  in  a  dying  state;  the 
adhesions,  on  which  the  prolongation  of  life  depended,  were  broken 
down,  and  general  peritonitis  was  established.  The  almost  complete 
secondary  perforation  of  the  caecum  is  an  illustration  of  the  course 
which  suppuration  sometimes  takes. 

CASE  CXX — Local  Peritonitis.  Perforation  of  Appendix  Cceci. 
Strangulation  of  the  Ileum  bg  the  Appendix. — A  young  lady  about  twenty- 
three  years  of  age  jumped  from  a  gate  about  a  year  before  her  death  and  ex- 
perienced pain  at  the  lower  part  of  the  abdomen,  with  slight  vomiting  and 
some  uneasiness  for  several  days  ;  she  remained,  however,  in  apparently  good 
health  till  August  13th,  1858,  when,  after  partaking  of  veal  and  a  glass  of 
port  wine  at  dinner,  severe  pain  at  the  lower  part  of  the  abdomen  came  on, 
the  pain  extending  from  the  hypogastric  to  the  epigastric  region.  The  next 
day  the  bowels  were  moved,  but  the  pain  towards  the  right  iliac  region  still 
remained,  and  she  felt  ill.  On  the  16th  her  medical  attendant  saw  her,  and 
found  her  suffering  from  pain  in  the  abdomen,  with  an  anxiety  of  expression 
which  appeared  to  indicate  more  than  ordinary  colic.  Aperient  medicine 
was  administered,  and  the  bowels  were  moved  on  the  17th  ;  she  stated  that 
the  pain  was  partially  relieved,  and  that  she  felt  better.  On  August  18th, 
in  the  evening,  severe  vomiting  of  offensive  matter  came  on  ;  the  pain  con- 
tinued at  the  lower  part  of  the  abdomen,  and  there  was  very  little  tympani- 
tis. The  vomiting  ceased,  and  the  pain  partially  subsided ;  the  abdomen  was 
still  tense  at  the  lower  part,  and  the  tympanitis  increased ;  the  pulse  con- 
tinued below  100 ;  the  urine  was  abundant ;  but  the  patient  became  more 
prostrate.  A  large  injection  of  cold  water  was  administered.  The  bowels 
acted  at  2  A.  M.  on  August  27th,  and  I  was  requested  to  see  her  in  consul- 
tation the  same  day.  At  10  A.  M.  I  found  her  with  a  flushed  face  and  with 
a  distressed  and  anxious  expression ;  the  skin  was  clammy ;  the  abdomen 
was  flattened  at  its  upper  part;  but  below  the  umbilicus,  and  especially 
towards  the  right  iliac  region,  it  was  very  tense,  tympanitic,  and  tender  on 
pressure.  A  rounded  and  dense  mass  could  be  felt  in  the  region  of  the 
caecum  and  at  the  termination  of  the  ileum.  No  evidence  could  be  found  of 
distension  of  the  transverse  or  descending  colon,  nor  could  enlarged  coils  of 
intestine  be  observed  through  the  parietes,  and  there  was  evidently  greater 
distension  of  the  right  than  of  the  left  loin.  The  vomiting  had  ceased,  the 
tongue  was  slightly  furred,  the  gums  were  sore  from  the  action  of  mercury  ; 
about  a  pint  of  urine  had  passed,  and  menstruation  had  come  on.  The  pulse 
was  120,  and  irritable;  the  respiration  40.  She  had  not  passed  any  flatus 
nor  blood  from  the  bowels,  but  an  evacuation  had  been  produced  by  the  in- 
jection a  few  hours  previously ;  she  had  had  sleep  during  the  night, 
mercurial  which  had  been  ordered  was  now  omitted,  and  opium  gr.  ss  given 
every  four  hours.  Till  September  3d  she  continued  in  a  hopeful  state,  but 


340  ON    DISEASES    OF    THE    CJECUM 

was  very  prostrate,  and  the  bowels  acted.  In  the  afternoon  of  that  day  she 
suddenly  awoke  from  sleep  with  great  distress  of  breathing,  and  died  in  a 
few  hours. 

Post-mortem  examination — -On  opening  the  abdomen  the  peritoneal  serous 
membrane  was  found  to  be  dry,  but  no  lymph  was  effused.  At  the  left  side 
of  the  caecum  there  was  considerable  peritoneal  inflammation,  bounded  by 
coils  of  ileum,  and  by  the  caecum.  At  this  part,  deeply  situated,  the  appen- 
dix cajci  passed  over  the  termination  of  the  ileum,  and  extended  to  the 
mesentery  of  a  portion  of  adjoining  ileum,  where  it  was  strongly  united,  and 
formed,  with  its  own  mesentery,  a  firm  loop.  The  mesentery  of  the  appendix 
was  adherent  to  a  small  gland,  which  completed  the  band  of  adhesion  with 
the  ileum  ;  at  the  same  site  another  coil  of  ileum  was  also  adherent  by  a 
broad  band  of  organized  adhesion.  The  termination  of  the  appendix  was 
softened,  sloughy,  ragged,  and  perforated;  but  the  appendix  itself  was  pale. 
Above  these  partially  constricting  bands  the  ileum  was  somewhat  distended, 
but  the  caecum  was  also  distended  with  flatus  and  feces,  showing  that  the 
strangulation  had  not  been  complete.  The  coats  of  the  ileum  towards  its 
termination  were  exceedingly  softened,  and  broke  down  in  several  parts  on 
removal ;  but  there  was  no  evidence  of  fecal  extravasation  before  death. 
The  caecum  was  also  softened.  The  opening  into  the  appendix  was  free. 
The  uterus  and  ovaries,  &c.,  were  healthy. 

In  this  case  there  was  evidence  during  life  of  local  peritonitis  in 
the  neighborhood  of  the  caecum  and  at  the  termination  of  the  ileum ; 
and  although  there  was  obstruction  of  the  bowels,  this  was  peculiar 
in  its  character ;  it  was  more  severe  than  in  ordinary  coecal  disease 
— for,  during  a  short  time,  there  was  stercoraceous  vomiting — and, 
on  the  contrary,  it  was  less  severe  than  in  complete  strangulation  of 
the  intestine,  for  the  bowels  were  many  times  acted  upon.  In  refer- 
ence to  the  position  of  the  obstruction  of  the  bowels,  the  ileum  and 
caecum  were  manifestly  concerned  ;  there  was  dulness  and  tympanitic 
distension  at  that  part,  with  tenderness,  and  there  was  no  distension 
of  the  transverse  nor  of  the  descending  colon;  but  the  pain  was 
situated  near  to  the  pubes,  and  nearer  to  the  median  line  of  the 
abdomen  than  in  simple  disease  of  the  caecum;  and,  although  it  was 
evident  that  the  symptoms  were  principally  due  to  inflammation 
connected  with  the  caecum  or  the  appendix,  it  appeared  more  than 
probable  that  the  pain  which  had  been  experienced  a  year  before, 
and  which  came  on  after  sudden  muscular  exertion,  might  have  been 
induced  by  some  abnormal  movements  of  the  intestine.  These 
opinions  were  confirmed  by  post-mortem  examination  ;  the  appendix 
caeci  had  been  adherent  for  some  time  across  the  lower  part  of  the 
ileum.  A  slight  attack  of  enteritis  produced  pain,  distension,  and 
almost  complete  occlusion  of  the  intestine ;  more  severe  inflammatory 
changes  then  became  manifested,  closely  resembling  those  of  ordinary 
disease  of  the  appendix ;  softening  and  perforation  of  the  appendix 
took  place,  but  the  peritonitis  was  localized  by  adhesions.  The 
strangulation  of  the  intestine  then  lessened,  and  the  bowels  were 
acted  upon  several  times.  Although  prostrate  and  exhausted,  there 
was  hope  of  recovery ;  but  sudden  collapse  supervened,  and  death 
followed  in  a  few  hours.  This,  we  believe,  arose  from  the  extension 
of  the  disease  to  the  general  peritoneum,  which  was  found  to  be  dry, 


AND    APPENDIX    C^ICI.  341 

although  sufficient  time  had  not  elapsed  for  lymph  to  be  effused. 
The  value  of  an  opiate  plan  of  treatment  was  well  shown  in  this 
case,  when  associated  with  complete  rest;  the  pain  subsided,  the 
bowels  acted,  and  the  vomiting  ceased.  The  mercurials  had  rendered 
the  contents  of  the  canal  more  fluid,  but  had  probably  induced  less 
elasticity  and  firmness  of  those  adhesions,  on  the  stability  of  which 
the  prolongation  of  life  depended,  for  by  them  only  was  the  perito- 
nitis localized. 

CASE  CXXI — Perforation  of  Appendix  Caci.  Abscess  behind  the 
Ascending  Colon  reopening  into  the  Colon.  Clot  in  Vena  Portce  and 
Mesenteric  Vein.  Pycemia — G—  D— ,  set,  23,  was  admitted  into  Guy's  on 
December  29th,  1875.  She  was  a  married  woman  ;  but  had  not  had  any 
children.  Four  months  previous  to  admission  she  had  had  a  miscarriage.  Her 
general  health  was  good,  and  her  illness  began  three  weeks  before  admission 
with  severe  pain  in  the  back,  and  with  diarrhoea  and  vomiting.  When  brought 
to  the  hospital,  she  had  an  anxious  expression  of  countenance,  was  wasted,  and 
appeared  to  suffer  pain.  She  lay  on  her  back  with  the  legs  drawn  up.  The 
tongue  was  dry,  the  teeth  and  gums  covered  with  sordes,  bowels  loose,  and 
the  motions  fluid  and  of  a  yellow  color.  The  hepatic  dulness  was  increased, 
and  there  was  much  tenderness  on  pressure.  The  pulse  was  small  and  com- 
pressible, 140.  Temperature  102.6°.  Respiration  30.  There  was  no 
maculae  observed.  A  little  crepitation  was  audible  at  the  bases  of  the  lungs, 
but  otherwise  they  were  healthy.  The  heart  was  healthy.  About  forty  • 
ounces  of  urine  were  drawn  off,  sp.  gr.  1010 ;  it  contained  a  slight  trace  of 
albumen  and  diminished  chlorides.  The  patient  moaned  from  pain,  but  ap- 
peared in  a  drowsy  state.  The  pupils  were  normal ;  she  had  not  suffered 
from  any  rigor.  On  the  following  day  she  was  in  the  same  state,  but  on  the 
31st  she  had  rigors  and  vomiting.  The  previous  evening  there  was  constant 
diarrhoea,  with  vomiting  and  retching.  Temperature  100°.  Pulse  130. 
Respiration  44.  On  January  1st  she  was  still  in  great  pain,  and  the  diarrhoea 
returned,  motions  ochry  and  loose.  Pulse  140,  weak  and  fluttering.  There 
were  flatulent  eructations,  and  again  vomiting.  She  complained  of  severe 
pain  about  the  heart,  and  great  restlessness  preceded  death.  She  remained 
sensible  till  near  her  death  at  6  P.  M. 

On  examination,  the  appendix  caeci  was  quite  divided  about  an  inch  from 
the  intestine,  and  it  opened  into  a  sloughy  abscess,  which  extended  behind 
the  bowel ;  the  abscess  opened  into  the  ascending  colon  by  a  round  opening, 
about  the  size  of  a  sixpenny-piece.  There  was  no  tubercle  in  the  lung  nor 
in  the  intestine,  and  no  other  ulceration  in  the  intestine.  There  was  no  evi- 
dence of  enteric  fever,  nor  of  any  foreign  body  having  lodged  in  the  bowel. 
The  mesenteric  vein  contained  pus.  The  vena  portae  contained  a  clot,  which 
had  formed  a  double  layer  upon  the  coats  of  the  vein,  and  had  allowed  some 
blood  to  pass  in  the  centre  of  the  vessel.  There  were  numerous  peripheral 
abscesses  of  small  size  in  the  liver.  The  spleen  was  healthy,  so  also  the 
kidneys. 

The  diagnosis  in  this  case  was  extremely  obscure  when  she  was  brought 
into  the  hospital.  It  was  evident  that  there  was  acute  disease  of  the  abdo- 
men, with  peritonitis,  but  how  it  had  originated  was  not  clear.  There  had 
been  diarrhoea,  but  there  was  no  proof  of  enteric  fever,  nor  was  there  evi- 
dence of  phthisis  or  tubercular  disease.  Insidious  disease  of  the  appendix 
led  to  ulceration,  then  to  suppuration  behind  the  caecum,  and  a  second  open- 
ing formed  into  the  bowel,  at  the  ascending  colon.  Suppuration  then  ex- 
tended into  one  of  the  branches  of  the  mesenteric  vein,  and  led  to  the  ob- 


342  ON    DISEASES    OF    THE    CAECUM 

ptruction  in  the  vena  portre  and  to  the  abscesses  in  the  liver.     The  pyiemia 
was  the  cause  of  the  later  symptoms  and  of  death. 

This  case  may  be  contrasted  with  one  more  recently  under  my  care 
in  Guy's,  in  which  equal  obscurity  attended  the  diagnosis.  There 
was  acute  inflammatory  disease  in  the  region  of  the  caecum,  but  in 
this  instance  the  caecum,  was  pushed  aside  from  its  normal  position 
and  the  disease  in  the  iliac  fossa  was  produced  by  perforation  of  the 
termination  of  the  ileum,  perhaps  from  enteric  fever. 

Many  of  these  cases  of  perforation  occur  even  at  an  earlier  period 
of  life  than  those  just  recorded.  In  my  notes  1  have  cases  at  the  age 
of  12,  14,  19.  &c.,  death  generally  taking  place  from  the  third  to  the 
seventh  day :  but  although  the  leading  symptoms  are  very  similar, 
and  well  marked,  each  one  has  its  own  minor  peculiarities.  The  de- 
tection of  foreign  substances  in  the  appendix,  without  any  severe 
irritation  having  been  produced,  is  by  no  means  uncommon  ;  thus  a 
pm  was  found  with  its  head  downwards,  and  its  point  extending  into 
the  coats,  half  surrounded  by  fibrous  membrane.  Again,  I  have 
observed  an  iron  nail  in  the  appendix,  without  injury  having  resulted 
from  its  presence;  shot,  and  various  substances  are  sometimes  thus 
lodged.  The  presence  of  feces  in  the  appendix  is  often  the  precursor 
of  ulceration  and  fatal  perforation.  In  the  volume  of  the  '  Guy's 
Reports'  for  1856  there  is  a  case  of  much  interest,  recorded  by  Dr. 
Hughes,  of  strumous  peritonitis  and  perforation  of  the  caecum  corning 
on  in  a  boy  aged  fourteen,  after  typhoid  fever.  Seven  months  after 
fever,  while  at  work,  sudden  and  severe  pain  came  on  in  the  abdomen, 
which  subsided  in  a  few  days,  but  again  returned,  continuing  for 
several  hours  in  each  attack.  When  brought  to  Guy's  the  pain  in 
the  abdomen  was  general,  with  tenderness,  and  there  was  much  fe- 
brile excitement.  After  several  weeks  the  general  distension  sub- 
sided, but  a  hard,  tolerably  defined  mass  was  felt  in  the  region  of 
the  caecum.  This  hardness  continued,  and  he  had  occasional  attacks 
of  severe  pain,  sometimes  with  diarrhoea;  hectic  supervened,  the 
skin  became  hot,  the  stomach  irritable,  and  he  became  exceedingly 
restless,  fretful,  and  distressed;  the  abdominal  viscera  moved  en 
masse;  he  sank  about  ten  weeks  after  admission. 

There  was  slight  tubercular  deposit  in  the  lungs;  but  the  abdomen 
presented  the  usual  appearance  of  strumous  peritonitis;  the  disease, 
however,  was  most  marked  in  the  region  of  the  caecum,  the  anterior 
surface  of  which  was  destroyed,  and  a  fecal  abscess  had  resulted ;  the 
termination  of  the  ileum  was  also  perforated.  Other  parts  of  the 
small  and  large  intestine  were  ulcerated. 

The  ulceration  consequent  on  the  typhoid  fever  in  this  child  ap- 
pears to  have  predisposed  to  slow  organic  changes  of  a  strumous 
character  in  the  abdomen. 

Cases  of  Cancerous  Disease. 

CASE  CXXII.  Cancer  of  the  Ccecum.     Abscess  in  the   Groin William 

J— ,  set.  56,  by  trade  a  coach  trimmer,  of  very  temperate  habits,  had  enjoyed 
excellent  health  till  he  ruptured  himself  in  carrying  a  heavy  weight;  he  after- 


AND    APPENDIX    C.ECI.  343 

wards  had  an  abscess  in  the  right  groin.  In  October,  1855,  he  experienced 
pain  and  sense  of  heat  at  the  lower  part  of  the  abdomen,  and  then  found  a 
swelling  about  the  size  of  a  walnut,  which  gave  him  great  pain  on  pressure, 
or  on  walking.  The  swelling  enlarged  day  by  day,  but  became  less  painful; 
and  night  sweats  came  on. 

On  admission  he  had  a  cachectic  appearance ;  and  in  the  right  iliac  region 
was  a  hard  swelling  extending  into  the  umbilical  region ;  it  descended  also 
below  Poupart's  ligament  on  the  right  side ;  the  inferior  part  was  firmer  than 
the  upper;  the  pain  was  increased  by  pressure  and  during  defecation.  The 
respiration  was  difficult,  but  the  chest  was  normal ;  the  urine  was  healthy, 
but  there  was  pain  after  passing  it.  The  appetite  was  tolerably  good.  He 
was  ordered  to  take  a  dose  of  castor  oil;  four  leeches  were  appfied  to  the 
tumor;  and  Dover's  powder  with  gray  powder  were  given  night  and  morning. 
Free  action  on  the  bowels  took  place,  which  lessened  the  abdominal  tumor, 
in  fact  it  had  almost  disappeared ;  but  the  tumor  in  the  thigh  remained  hard 
and  tender.  It  became  red,  more  swollen,  and  crepitant.  Severe  pain  in 
the  thigh  then  came  on,  and  a  free  incision  was  made  into  the  abscess;  about 
a  pint  of  fecal  matter,  with  gas,  was  discharged.  This  fecal  discharge  with 
pus  continued  very  abundant ;  the  edges  of  the  wound  sloughed,  and  a  second 
opening  formed  near  the  crest  of  the  ileum.  The  patient  gradually  became 
prostrate ;  and  for  more  than  a  month  before  his  death  he  had  very  trouble- 
some diarrhoea.  He  died  about  three  months  after  admission. 

On  inspection  of  the  abdomen  the  general  peritoneal  surface  was  found  to 
be  healthy;  the  small  intestines  were  collapsed.  There  was  an  old  inguinal 
sac  on  the  right  side  quite  free  and  empty.  Several  coils  of  small  intestine, 
the  lower  parts  of  the  ileum,  were  firmly  adherent  on  the  inner  side  of  the 
caecum,  at  the  brim  of  the  pelvis ;  and  the  caecum  itself  formed  the  anterior 
surface  of  a  firm  tumor.  On  carefully  removing  the  caecum  and  intestine,  it 
was  found  that  the  posterior  wall  of  the  cascum  was  destroyed  by  carcinoma- 
tous  ulceration,  and  offensive  fecal  matter  was  poured  out  from  beneath  the 
iliac  fascia;  and  the  abscess  extended  downwards  to  the  opening  on  the  thigh. 
There  was  also  an  irregular  nodulated  growth  extending  from  the  mucous 
membrane  of  the  cascum,  attached  anteriorly  near  the  valve,  and  surrounding 
the  intestine;  the  edges  were  exceedingly  vascular,  but  not  flocculent.  The 
section  of  the  thicker  portion  near  the  ileum  presented  yellowish-white  medul- 
lary structure,  and  consisted  of  an  aggregation  of  large  nuclei,  evidently 
medullary  cancer;  near  the  margin,  beautiful  capillaries  were  observed  dis- 
tended with  blood.  At  the  posterior  part  some  of  the  cellular  tissue  was 
infiltrated.  The  coil  of  ilenm  which  was  adherent  to  the  caecum  had  an 
irregular  transverse  opening  into  it,  and  was  much  injected.  The  remaining 
part  of  the  intestinal  canal  was  healthy,  so  also  the  mesenteric  and  lumbar 
glands.  The  liver  was  pale  and  somewhat  fatty.  The  kidneys  and  bladder 
were  healthy ;  so  also  the  thoracic  viscera. 

The  commencement  of  this  disease  was  different  from  ordinary 
caecal  mischief.  There  was  at  first  a  small  painful  tumor  in  the 
abdomen,  which  had  more  resemblance  to  cancerous  growth,  or  dis- 
eased gland,  than  cascal  disease  of  a  simple  inflammatory  character; 
the  disease  was  slow  in  its  progress,  hectic  was  developed,  and  the 
patient  ultimately  sank  from  exhaustion.  The  course  of  the  disease 
beneath  the  iliac  fascia  was  that  followed  in  most  cases  of  suppura- 
tion in  the  iliac  fossa.  In  other  cases  which  I  have  witnessed  of 
ulceration  commencing  at  the  posterior  surface  of  the  csecum,  and 


844  ON    DISEASES    OF    THE    CJ5CUM. 

leading  to  extravasation  into  the  cellular  tissue  of  the  iliac  fossa,  the 
disease  has  generally  been  of  a  cancerous  character. 

CASE  CXXIII.  Colloid  Cancer  of  the  Caecum.  Jaundice — Ann  C — , 
aet.  28,  was  admitted  into  Guy's  Hospital,  July  31st,  1860.  She  had  resided 
in  service  at  Woolwich ;  and  her  previous  health  had  been  tolerably  good, 
but  the  bowels  had  always  been  irregular.  On  July  22d  she  was  seized  with 
vomiting,  which  continued  till  the  time  of  admission,  but  was  relieved  by 
milk  and  lime  water.  The  vomiting  came  on  in  the  evening,  and  was  pre- 
ceded by  pain  and  soreness  in  the  mouth ;  pain  then  came  on  in  the  right 
side.  Since  July  there  had  been  no  appearance  of  the  menses ;  previously 
she  had  suffered  from  dysmenorrhoea.  On  admission  she  was  pale,  and  had 
an  anxious  and  distressed  expression ;  she  was  nervous  and  easily  excited. 
The  pulse  was  compressible  and  the  heart  irritable;  the  chest  was  healthy, 
and  she  had  no  cough.  The  abdominal  muscles  were  rigid;  and  immediately 
beneath  the  skin  a  defined,  hard,  and  elongated  tumor,  placed  somewhat 
transversely,  could  be  felt  in  the  region  of  the  cascum  and  ascending  colon ; 
the  pain  on  pressure  was  severe,  but  was  especially  complained  of  when  the 
pressure  was  sudden.  The  part  was  dull  on  percussion ;  the  bowels  were 
easily  acted  upon.  After  food  flatulent  distension  came  on,  and  she  often 
complained  of  severe  pain  in  the  region  of  the  crecum  directly  after  swallowing 
fluids.  She  was  nervous  and  excitable,  and  the  pain  was  manifestly  increased 
when  attention  was  directed  to  the  part.  Dover's  powder,  and  the  steel  and 
aloetic  pill  afforded  considerable  relief,  and  she  left  the  hospital  on  November 
13th.  She  returned,  however,  in  six  weeks,  much  worse;  jaundice  had  come 
on  a  few  days  previously,  and  she  was  very  ill.  The  mind  was  oppressed, 
the  pulse  was  very  compressible,  and  she  died  in  ten  days  from  this  hepatic 
complication. 

Inspection. — The  thoracic  viscera  were  healthy.  In  the  posterior  wall  of 
the  right  lumbar  and  ileo-hypogastric  regions  the  peritoneum  was  studded 
with  small  yellowish  tubercles  of  cancerous  matter.  The  stomach  was  drawn 
down  by  the  great  omentum,  so  as  to  be  visible  below  the  liver.  The  ileum 
near  the  csecum  became  gradually  thickened  and  rigid,  from  the  growth  of 
cancerous  matter  of  the  appearance  and  consistence  of  old  honey  in  a  crys- 
talline state.  The  ileo-caecal  valve  was  obliterated  ;  the  caecum  and  ascend- 
ing colon  were  very  thick  and  rigid  ;  the  peritoneum  over  them  was  involved 
in  cancerous  disease,  and  the  muscular  coat  could  not  be  distinguished.  The 
coats  of  the  intestine  were  an  inch  in  thickness  just  above  the  ctecum,  and 
the  calibre  of  the  bowel  was  much  diminished  in  size ;  at  this  part  also  the 
mucous  membrane  was  ulcerated  for  the  space  of  several  square  inches.  The 
mesenteric  glands  were  enlarged  and  infiltrated  with  cancerous  matter.  The 
glands  about  the  head  of  the  pancreas  compressed  the  common  bile-duct. 
The  lumbar  glands  also  were  infiltrated.  The  kidney  contained  some  cancer- 
ous tubercles.  The  right  ovary  was  enlarged  to  the  size  of  an  egg,  and  was 
roughened  and  tubercular  on  the  surface.  The  peritoneal  veins  at  that  part 
of  the  pelvis  were  enlarged.  The  walls  of  the  caecum  and  the  last  six  inches 
of  the  ileum  presented  a  beautiful  specimen  of  colloid  cancer.  The  mucous 
membrane  was  nearly  half  an  inch  in  thickness,  and  of  a  gummy  appear- 
ance ;  it  presented  delicate  fibres  forming  cellular  spaces,  which  were  filled 
with  large  nucleated  cells ;  portions  of  the  cellular  interspaces  consisted  of 
very  minute  granules,  as  if  from  degenerating  fibre ;  numerous  clusters  of 
granules  were  also  observed.  Beneath  the  thicker  portion  of  the  diseased 
mucous  membrane  was  a  red  layer,  consisting  apparently  of  degenerated 
muscular  fibre,  or  rather  of  cancerous  tissue,  in  the  place  of  the  muscular, 
and  formed  by  an  immense  number  of  nucleated  cells. 


AND    APPENDIX    CJECI.  345 

The  cause  of  death  in  this  case,  was  the  obstruction  of  the  bile- 
el  nets  by  enlarged  pancreatic  glands.  The  patient  was  extremely 
nervous  and  excitable,  and  at  the  onset  of  the  disease  it  seemed 
doubtful  whether  the  symptoms  arose  from  ovarian  irritation.  It 
was,  however,  soon  evident  that  there  was  organic  disease  of  the 
caecum  or  small  intestine.  The  mischief  was  more  circumscribed 
than  in  ordinary  cascal  inflammation,  and  there  was  an  absence  of 
febrile  symptoms  and  of  local  peritonitis.  It  might  have  been 
doubtful  whether  ovarian  disease  had  set  up.  enlargement  of  the 
lumbar  glands;  but  the  manner  in  which  pain  came  on  in  the  tumor 
directly  after  food  had  been  swallowed,  pointed  to  intestinal  mis- 
chief; and  the  tumor  appeared  in  her  emaciated  state  to  be  very 
superficial,  immediately  beneath  the  skin,  and  more  distinct  than  it 
would  have  been  from  enlarged  glands ;  neither  was  the  growth  in 
the  position  of  mesenteric  or  ornental  tumors. 

CASE  CXXIV.  Appendix  Cceci  in  the  Inguinal  Canal. — James  C — , 
get.  16.  The  testes  had  not  descended,  and  the  appendix  was  adherent  in  the 
inguinal  canal ;  the  small  intestine  was  fixed  in  the  pelvis.  The  symptoms 
of  hernia  came  on,  and  an  explorative  operation  was  performed.  Peritonitis 
supervened,  and  after  death  purulent  effusion  was  found  in  the  abdominal 
cavity. 

These  cases  are  recognized  by  surgeons  as  belonging  to  one  of  the 
forms  of  irreducible  hernia. 

Intussusception  of  the  ileum  into  the  caecum  and  ascending  colon 
is  of  not  unfrequent  occurrence :  and  its  symptoms  might  be  mis- 
taken for  simple  inflammatory  disease  of  the  caecum.  This  subject 
will  be  again  referred  to  in  speaking  of  intussusception  generally. 

In  many  of  the  morbid  changes  of  the  caecum  to  which  allusion 
has  been  made,  constipation  is  a  more  or  less  constant  sign,  and 
there  is  danger  of  yielding  to  the  temptation  of  administering  pur- 
gatives ;  these  medicines  rarely  effect  the  desired  object  until  inflam- 
matory irritation  has  subsided. 


346 


CHAPTER  XI. 

ON  DIARRH(EA. 

DIARRHCEA  consists  in  the  abnormal  frequency  of  evacuation  of 
the  bowels,  as  defined  by  Cullen,  "Dejectio  frequens;  morbus  non 
contagiosa;  pyrexia  nulla  primaria:"  and  it  arises  generally,  but 
not  exclusively,  from  an  irritated  condition  of  the  large  intestine. 

It  manifests  itself  in  various  forms,  some  of  which  have  received 
distinctive  appellations,  as  Diarrhoea  crapulosa,  biliosa,  mucosa,  or 
catarrhalis,  dysenterica,  and  choleraica,  to  which  might  be  added  ner- 
vosa,  and  colliqualiva. 

Diarrhoea  crapulosa  is  that  state  in  which  there  is  an  unnatural 
fluidity  and  excess  of  fecal  excretion,  in  which  the  evacuations  are 
healthy  in  character,  but  in  excessive  frequency  and  fluidity;  in 
some  cases  very  large  quantities  are  discharged  without  any  discom- 
fort, but,  on  the  contrary,  with  relief  to  the  patient.  This  form  of 
diarrhoea  should  not  be  checked  when  it  is  a  natural  discharge ;  but 
more  frequently  it  is  the  sequence  of  irritating  and  undigested  food. 
Too  great  a  quantity  may  have  been  taken,  and  a  portion  of  it  may 
have  passed  into  the  intestine  crude  and  partially  dissolved;  or  from 
its  insoluble  character  portions  of  the  food,  as  the  woody  fibre  of 
vegetables  and  fruit,  may  have  remained  unchanged  by  the  gastric 
juice,  and  irritate  the  intestine.  Again,  active  mental  or  bodily 
exercise  immediately  after  a  rneal,  which  has  been  suitable  both  as 
to  quality  and  quantity,  may  interfere  with  the  proper  solution  of 
food,  and  lead  to  its  hasty  passage  into  the  duodenum. 

When  the  alimentary  canal  becomes  in  this  way  loaded  with  un- 
dissolved  ingesta,  pain  of  a  griping  and  twisting  character  ensues, 
from  irregular  peristaltic  action  and  from  distension.  The  abdomen 
becomes  full ;  the  skin  and  complexion  sallow ;  the  tongue  is  furred; 
the  pulse  is  compressible ;  headache  and  giddiness  are  often  present; 
the  sleep  is  disturbed ;  the  bowels  act  frequently  and  irregularly, 
and  the  motions  contain  undigested  substances,  with  fluid  feces  or 
with  firm  scybala.  Considerable  soreness  is  at  times  experienced  in 
the  course  of  the  large  intestine,  and  distressing  tenesmus  arises  from 
the  irritation  of  the  mucous  membrane  of  the  rectum. 

The  term  lientary  is  used  to  designate  the  condition  in  which  the 
food  is  passed  almost  unacted  upon,  either  by  the  gastric  or  intestinal 
secretions,  and  in  a  very  short  time  after  having  been  taken.  This 
state  arises  from  excessive  irritability  of  the  whole  intestinal  tract, 
with  disordered  secretions;  it  is  not  unfrequent  in  children  after 
protracted  diarrhoea,  and  gastro-enteritis.  It  is  of  common  occur- 
rence among  the  out-patients  of  large  hospitals ;  and  in  not  a  few 
cases  leads  to  a  fatal  termination. 


ON    DIAKRHCEA.  347 

Bilious  Diarrhoea  is  also  a  form  of  disease  produced  by  the  effusion 
of  irritating  substances  into  the  intestine ;  not,  however,  from  with- 
out, but  from  the  liver,  and  possibly  from  the  pancreas  follicular 
glands. 

The  secretion  of  the  liver  becomes  either  excessive  in  quantity, 
or  irritating  in  quality ;  and  the  contents  of  the  canal  are  apparently 
hurried  onward,  and  evacuated  as  frequent  loose  and  bilious  dejec- 
tions. The  causes  of  this  state  are  various,  and  sometimes  the 
disorder  of  the  liver  is  really  secondary  to  an  irritable  condition  of 
the  intestine  itself,  due  to  excess,  especially  of  stimulants.  Exposure 
to  cold  and  wet  induces  diseases  of  this  kind,  especially  in  the 
autumnal  season  of  the  year.  The  symptoms  are  somewhat  similar 
to  those  previously  mentioned;  the  pain  is  slight,  unless. the  disease 
become  aggravated;  the  tongue  is  furred;  the  complexion  is  sallow; 
some  febrile  excitement  is  present  with  frontal  headache ;  pain  in 
the  abdomen  and  in  the  hypochondriac  region.  This  form  of  diar- 
rhoea is  sometimes  epidemic,  attacking  considerable  numbers  exposed 
to  similar  exciting  causes ;  and  when  severe,  and  accompanied  with 
colic  or  spasmodic  pain  in  the  abdomen  and  legs,  and  especially  with 
vomiting,  it  constitutes  English  cholera,  and  often  leads  to  great 
prostration  of  strength.  The  countenance  becomes  haggard,  the 
eyes  appear  sunken,  the  pulse  is  exceedingly  compressible  and 
failing,  the  temperature  below  normal,  the  tongue  is  brown,  and  the 
patient  too  frequently  sinks  exhausted,  especially  if  very  young,  or 
advanced  in  life,  or  if  already  prostrate  from  other  disease. 

Abnormal  conditions  of  the  bile  tend  to  produce  other  modifica- 
tions; thus,  the  motions  in  diarrhoea  are  sometimes  in  a  state  of 
fermentation  ;  they  are  watery,  frothy,  and  only  contain  fluid  fecal 
matter.  This  I  have  seen  very  prominently  in  a  case  of  phthisis, 
in  which  there  was  probably  some  ulceration  of  the  intestine,  when 
the  evacuations  consisted  of  long  shreds  of  mucus  and  casts  composed 
of  columnar  epithelium  and  nuclei.  After  a  few  weeks  this  con- 
dition subsided  under  the  use  of  cusparia,  sulphuric  acid,  and  opium, 
with  occasional  starch  injections,  but  it  was  followed  by  very  severe 
pain  in  the  course  of  the  colon,  and  by  frothy,  yeast-like  evacuations. 
For  this  state  I  used  injections  of  charcoal,1  3ij  to  about  a  pint  of 
thin  barley-water,  with  great  relief:  the  character  of  the  evacuations 
improved,"  and  in  a  short  time  became  naturally  fecal,  the  pain 
diminished,  and  the  strength  increased.  I  afterwards  gave  the 
patient  several  grains  of  myrrh,  twice  or  three  times  a  day,  with 
manifest  improvement,  till  she  left  the  hospital  several  months  later. 

Diarrhoea  sometimes  occurs  with  an  absence  of  bile  in  the  evacua- 
tions ;  in  jaundice  this  may  be  the  case ;  it  is  so  in  cholera ;  and  to- 
wards the  close  of  chronic  disease,  the  liver  may  cease  to  pour  put 
its  ordinary  secretion.  I  have  seen  it  in  a  patient  slowly  sinking 
from  the  exhaustion  consequent  on  diabetes,  without  phthisis.  The 
motions  were  in  that  case  often  quite  white,  like  water  frothy  from 
an  abundance  of  soap. 

'  See  Dr.  Theophilus  Thompson's  Lectures  on  Phthisis. 


348  ON    DIARHIKEA. 

There  is,  also,  a  form  of  diarrhoea  arising  from  the  inhalation  of 
noxious  effluvia,  which  is  closely  allied  to  that  just  described  ;  the 
fumes  of  sulphuretted  hydrogen  gas  are  absorbed  by  the  lungs,  and 
through  their  minute  capillaries  enter  the  blood ;  the  gas  is  circu- 
lated and  acts  as  a  poisonous  agent  on  that  vital  fluid,  and  if  con- 
centrated, proves  rapidly  fatal;  if  less  concentrated,  it  produces 
headache,  and  frequently,  also,  diarrhoea.  It  appears,  that  not  only 
are  the  secretions  of  the  liver  and  alimentary  canal  changed,  but 
that,  by  means  of  this  excessive  action  of  the  abdominal  viscera,  the 
poison  is  eliminated  from  the  system.  So  rapid  is  this  agent  in  its 
action,  that  to  be  present  for  a  short  time,  even  a  quarter  of  an  hour, 
in  a  dissecting  room,  will,  in  some  persons,  produce  distressing  diar- 
rhoea. 

In  typhoid  fever,  and  in  phthisis,  ulceration  of  the  small  intestine 
is  frequently  found  to  be  accompanied  with  diarrhoea;  of  these  we 
have  spoken  elsewhere ;  in  some  of  these  cases,  the  large  intestine  is 
involved,  but  in  others,  when  the  diarrhoea  has  been  severe,  such 
has  not  been  the  case.  It  would  appear  that  the  continuity  of  struc- 
ture with  the  ulcerated  ileum,  the  irritating  excreta,  as  well  as  the 
changed  and  probably  accelerated  peristaltic  action  of  the  small  in-, 
testine,  tend  to  excite  over-action  of  the  colon,  and  thus  to  set  up 
diarrhoea. 

Catarrhal  and  mucous  diarrhoea  arises  from  a  state  of  slight  in- 
flammatory disease,  closely  allied  to  ordinary  coryza,  affecting  the 
mucous  membrane  of  the  large  intestine.  The  secretion  is  at  first 
checked,  but  afterwards  greatly  increased,  and  a  watery  feculent 
mucus  is  discharged  mixed  with  the  ordinary  feces.  This  state  may 
continue  for  several  days,  or  even  for  a  much  longer  period :  the 
motions  are  loose,  and  somewhat  watery;  and  if  the  rectum  be  af- 
fected, considerable  tenesmus  is  produced ;  the  pain  and  febrile  ex- 
citement are  slight,  but  the  strength  of  the  patient  is  reduced,  and 
he  is  unequal  to  his  usual  duties;  the  tongue  is  clean,  the  pulse  is 
compressible;  the  bladder  sometimes  sympathizes  with  this  irrita- 
tion, and  a  frequent  desire  to  pass  urine  is  induced ;  in  little  girls, 
also,  a  muco-purulent  secretion  often  takes  place  from  the  vulva ; 
redness  of  the  parts  is  produced  with  smarting  pain,  and  the  idea 
has  sometimes  been  suggested  that  the  child  has  been  cruelly  treated. 

In  this  form  of  diarrhoea  the  evacuations  contain  a  considerable 
quantity  of  mucus,  and  a  little  blood  is  often  observed ;  these  are 
especially  present  when  irritation  occurs  very  low  down  in  the  rec- 
tum, or  is  set  up  by  hemorrhoids;  and  the  mucus  will  sometimes 
pass  both  before  and  after  the  dejection. 

In  infants  the  disease  closely  resembles  gastro-enteritis,  or  it  is, 
perhaps,  rather  identical  with  it,  but  differing  in  degree,  as  a  greater 
or  less  part  of  the  alimentary  canal  is  affected ;  in  these  cases  the 
whole  tract  sometimes  becomes  rapidly  involved,  and  great,  if  not 
fatal  prostration,  rapidly  ensues.  (See  Muco-Enteritis.) 

As  the  bilious  diarrhoea,  before  mentioned,  it  is  in  very  young  or 
aged  subjects  that  catarrhal  diarrhoea,  or  catarrhal  inflammation  of 
the  large  intestine,  leads  to  more  serious  disease,  but  it  is  also  found 


ON    DIARRH(EA.  349 

amongst  those  in  whom  chronic  or  more  exhausting  disease  has 
existed. 

This  catarrhal  diarrhoea  not  unfrequently  becomes  a  chronic  dis- 
ease, the  more  severe  symptoms  cease,  but  still  the  bowels  do  not 
act  in  their  normal  manner ;  constipation  often  ensues,  and  after- 
wards a  fresh  looseness  of  the  bowels,  and  this  alternation  is  often- 
times repeated,  or  the  more  solid  motions  are  followed  by  a  discharge 
of  mucus  coating  the  feces ;  sometimes  the  mucus  is  passed  in  con- 
siderable quantity  after  the  evacuation,  or  it  forms  an  elongated 
flake  or  caste  of  the  intestine.  I  have  observed  this  condition  fol- 
lowing severe  disease  of  the  intestines  of  a  dysenteric  character,  and 
it  is  sometimes  associated  with  a  state  of  chronic  congestion  of  the 
liver ;  again,  it  is  often  perpetuated  by  the  presence  of  hemorrhoids, 
and  by  ovarian  disease.  It  may  exist  for  many  years  without  caus- 
ing much  derangement  of  health. 

Morbid  Anatomy. — Many  instances  have  been  known  of  fatal  diar- 
rhoea in  which  the  appearance  of  the  mucous  membrane  has  been 
normal,  its  congestion  has  entirely  disappeared,  and  a  thin  mucus 
only  has  been  found  upon  the  membrane.  But  this  is  not  always 
the  case,  and  there  are  several  recognized  pathological  changes 
which  are  frequently  present.  First  of  these,  because  most  frequent 
and  therefore  the  more  important,  is  a  vivid  injection  in  more  or 
less  isolated  patches. 

2dly.  When  the  diarrhoea  has  been  chronic,  the  mucous  membrane 
is  not  unfrequently  covered  by  a  thick  layer  of  mucus,  and  presents 
a  gray  color.  1  have  frequently  examined  membranes  thus  changed 
(as  before  described  ;  see  Duodenum  and  Caecum),  and  have  observed 
that  the  color  arises  from  minute  particles  of  dark  pigmental  matter 
deposited  in  the  substance  of  the  mucous  membrane.  Prolonged 
congestion  is  known  to  give  rise  to  similar  pigmentary  changes  in 
many  parts,  as  in  the  skin,  liver,  lung,  heart,  &c.,  and  whenever 
this  pigmentary  deposit  occurs  it  is  found  to  be  due,  as  I  have 
described  here,  to  grains  of  varying  tint — orange,  red,  brown,  or 
black.  One  must  regard  these  grains  as  the  remnants  of  actually 
extravasated  blood  or  to  the  arrest  of  some  of  the  oxidizing  or  other 
processes  which  the  blood  coloring  matter  probably  undergoes  in  its 
passage  through  the  various  tissues. 

In  the  large  intestine,  this  pigmental  deposit  is  found  in  minute 
circles  around  the  follicles. 

3dly.  The  mucous  membrane,  and  also  the  connecting  cellular 
tissue,  become  thickened. 

4thly.  Minute  ulceration,  probably  follicular,  is  found  extending 
through  more  or  less  of  the  length  of  the  colon.  These  ulcerations 
are  about  one-sixteenth  of  an  inch  in  diameter,  and  present  a  minute 
black  zone  around  each  of  them.  This  state  would  be  regarded  by 
many  as  the  result  of  dysentery. 

Dysenteric  Diarrhoea. — Purging  is  the  most  marked  symptom  of 
dysentery,  and  the  lesser  degrees  of  irritation  which  we  have  con- 
sidered under  the  term  of  catarrhal  diarrhoea  might  be  regarded  as 
a  form  of  dysentery  of  the  mildest  character.  In  dysentery,  how- 


350  ON    DIARRHOSA. 

ever,  the  diseased  mucous  membrane  rapidly  passes  into  a  state  of 
ulceration,  and  blood  is  discharged  with  the  fecal  excreta. 

In  Choloraic  Diarrhcea  a  thin,  very  abundant  watery  mucus  is 
discharged  from  the  alimentary  canal.  The  evacuation  may  have 
very  little  color,  and  present  the  appearance  of  rice-water.  It  is 
often  alkaline  in  character,  and  consists  of  nuclei  and  epithelial  cells 
in  various  degrees  of  development.  After  death  the  membrane  is 
found  to  be  entire,  and  pale  or  sodden ;  the  solitary  and  Peyer's 
glands  are  enlarged.  In  many  cases  of  uncomplicated  cholera 
which  I  have  examined,  no  further  morbid  appearance  was  pre- 
sented. 

Of 'late  years  a  belief  in  a  fungous  growth  has  been  revived,  and 
the  dejections  of  cholera  have  been  said  by  Hallier  and  others  to 
contain  specific  spores.  Some  very  careful  and  prolonged  observa- 
tions, however,  by  Drs.  Lewis  and  Cunningham  in  India,  controvert 
this  opinion. 

The  symptoms  are  those  of  rapid  prostration,  with  pallor  and 
sunken  eye ;  the  pulse  is  compressible,  the  tongue  is  cool,  and  the 
voice  is  often  scarcely  audible ;  the  abdomen  is  collapsed,  and  the 
urine  is  scanty  in  quantity;  the  stomach  is  often  exceedingly  irrita- 
ble, so  that  everything  is  at  once  rejected  from  it;  the  alvine  evacua- 
tions are  generally  frequent,  and  of  the  character  before  mentioned; 
and  severe  cramps  in  the  legs  and  in  the  abdomen  are  often  present. 
This  state  may  pass  into  one  of  profound  collapse,  even  after  one 
evacuation  of  the  character  of  rice-water,  but  as  the  prostration 
subsides,  in  favorable  cases,  I  have  never  observed  the  febrile  excite- 
ment which  is  secondary  to  true  cholera. 

Another  kind  of  diarrhoea  is  that  which  has  been  correctly  called 
Serous,  and  which  is  frequently  observed  in  albuminuria.  A  drop- 
sical condition  of  the  mucous  membrane  is  induced,  and  the  serous 
exudation  from  the  overcharged  capillaries  leads  to  watery  discharge 
into  the  colon,  and  thus  to  diarrhoea.  This  state  of  the  mucous 
membrane  is  precisely  analogous  to  the  oedema  of  the  lungs,  and  to 
anasarca  of  the  cellular  tissue  in  renal  disease.  So  frequently  is 
diarrhoea  present  in  these  cases,  that  it  may  almost  be  regarded  as  a 
symptom  of  the  disease,  and  when  moderate  is  beneficial  in  its  results. 
It  is  the  action  we  often  seek  to  produce  artificially  by  powerful 
hydragogue  cathartics,  so  as  to  diminish  the  quantity  of  urea  circu- 
lating in  the  blood,  and  to  relieve  the  oppressed  kidney.  All  these 
fluid  evacuations  contain  urea,  as  does  the  gastric  juice  and  the 
mucus  discharged  from  the  lungs. 

Another  class  of  cases  which  can  scarcely  be  placed  among  those 
previously  mentioned,  arise  from  fright,  from  excessive  mental  agita- 
tion, from  want  of  food,  and  from  exhausting  disease ;  the  former 
cases  are  of  mental  origin,  the  latter  constitute  what  is  sometimes 
called  "colliquative  diarrhoea;"  and  the  condition  of  the  mucous 
membrane  corresponds  to  that  of  the  skin,  from  which  profuse 
partial  sweats  break  out. 

In  fright-  the  capillaries  of  the  face  become  blanched,  and  the 
blood  leaves  the  whole  of  the  surface;  the  cavities  of  the  heart  are 


ON    DIAKRHGEA.  351 

increasingly  distended,  hence  tlifcdis.com fort  there  experienced,  mill 
the  mucous  membrane  of  the  intestine  is  probably  also  engorged  ; 
therefore  the  discharge  from  the  mucous  membrane  is  to  a  "certain 
extent  beneficial  in  relieving  internal  congestion.  The  intimate  con- 
nection of  the  sympathetic  nerve  with  the  centres  of  thought  and 
feeling  is  the  probable  explanation  of  these  instances  of  diarrhoea 
following  mental  agitation. 

In  scurvy,  purpura,  starvation,  &c.,  the  altered  character  of  the 
blood  leads  to  the  effusion  of  serum,  or  blood,  into  the  mucous  mem- 
brane, or  into  the  canal  itself,  corresponding  to  the  effusion  into  the 
skin.  In  some  fatal  cases  of  purpura,  the  whole  of  the  mucous 
membrane  of  the  alimentary  canal  is  studded  with  spots  of  ecchy- 
mosis.  An  interesting  case  of  this  kind  occurred  at  Guy's  Hospital 
in  1856,  in  a  young  man  who  had  been  starved  to  death. 

Discharge  of  blood,  or  melsena. — Obstruction  of  the  portal  circula- 
tion either  from  pulmonary,  from  cardiac,  or  from  hepatic  disease, 
leads  to  great  engorgement  of  the  mucous  membrane  of  the  whole 
alimentary  canal ;  and  this  congestion  may  cause  hemorrhage  from 
the  bowels.  In  examining  the  mucous  membrane  in  these  cases,  it 
is  very  common  to  find  points  of  ecchymosis,  and  the  capillary 
vessels  of  the  membrane  much  distended.  Under  a  low  magnifying 
power  we  find  the  capillaries  beautifully  injected,  with  extravasated 
blood  between  them,  still,  however,  restrained  by  the  unbroken  epi- 
thelial surface  and  its  basement  membrane ;  if  the  rupture  of  this 
membrane  occur  blood  is  extravasated.  The  discharge  of  blood 
may  be  a  symptom  of  various  diseases;  thus,  ulceration  is  a  fre- 
quent cause  of  hemorrhage  from  the  bowels,  and  the  ulcer  may  be 
located  in  any  part  of  the  canal;  in  the  stomach  and  duodenum  from 
various  causes ;  in  the  small  intestine  in  fever  and  in  phthisis ;  in 
the  colon  in  dysentery,  &c. 

The  blood  does  not  always  present  the  same  appearance ;  if  it  arise 
from  hemorrhoidal  vessels  the  blood  will  be  florid,  and  precede  or 
follow  the  dejection;  if  it  come  from  some  higher  part  of  the  canal 
it  is  incorporated  with  the  feces;  and  when  it  has  traversed  a  con- 
siderable portion  of  the  canal,  it  becomes  altered  by  admixture  with 
the  secretions  from  the  mucous  membrane.  This  is  the  case,  to  some 
extent,  when  the  blood  is  poured  into  the  caecum,  but  is  especially 
so  whenever  it  has  been  extravasated  into  the  stomach  ;  the  acids  of 
the  gastric  juice  act  upon  the  effused  blood,  so  that  it  becomes  black, 
and  when  discharged  from  the  intestine  it  resembles  a  pitchy  fluid, 
constituting  true  rnelaena. 

The  symptoms  of  diarrhoea  have,  perhaps,  been  sufficiently  de- 
scribed in  mentioning  its  several  forms;  and  they  vary  according 
to  the  cause.  In  the  simplest  form  there  is  neither  pain  nor  consti- 
tutional disturbance;  in  more  aggravated  cases  there  may  be  severe 
colic,  and  febrile  excitement ;  and  generally,  unless  there  be  hepatic 
disturbance  and  derangement  of  the  whole  mucous  tract,  the  tongue 
is  clean,  it  is  then  furred  and  injected,  and  in  typhoid  prostration 
assumes  a  brownish  color.  The  pulse  is  compressible,  and  the  con- 


352  ON    DIARRIICEA. 

n  0   \  ^  i  ^  o  I  J 


prostration  is  often  voryjijnrming,  especially  in  infants  and 
aged  parsons,  mid  in  SOUK;  cases  it  leads  to  a  fatal  result. 

11  It!  is  important  carefully  to  mark1  the  character  of  the  evacuations; 
first,  as  to  the  admixture  of  undigested  substances  ;  secondly,  as  to 
the  fluidity  of  the  evacuations;  a  simple  fluid  state,  with  normal 
excreta,  indicates  irritation  of  the  mucous  membrane  in  a  slight 
degree;  thirdly,  the  presence  of  mucus  is  evidence  of  more  severe 
irritation  of  the  colon;  this  is  sometimes  found  in  excessive  quantity, 
and  is  easily  recognized  by  pouring  the  evacuation  from  one  vessel 
into  another;  fourthly,  if  more  acute  disease  of  the  colon  exist,  de- 
tached portions  of  feces  are  found  floating  on  the  fluid,  which  from 
the  rapidity  of  its  discharge,  and  possibly  also  from  intestinal  changes, 
is  often  frothy,  from  the  admixture  of  air;  fifthly,  in  severe  diar- 
rhoea, thin  watery  fluid  may  be  discharged  with  scybala,  and  with 
sedimentary  portions  of  fecal  matter;1  sixthly,  thin  fluid,  almost  like 
clear  water,  may  be  passed,  as  in  some  cases  of  albuminuria,  from 
an  cedematous  condition  of  the  membrane,  or  like  rice-water  in 
choleraic  diarrhoea,  or  like  soap-suds  when  with  colliquative  diar- 
rhoea the  hepatic  secretion  is  also  checked  ;  seventhly,  the  feces  are 
sometimes  discharged  in  a  state  indicative  of  fermentative  action, 
and  a  frothy  surface  is  produced  of  the  appearance  of  yeast,  and  the 
whole  discharge  closely  resembles  the  matters  occasionally  ejected 
from  the  stomach  in  obstructive  disease  at  the  pylorus;  eighthly,  as 
to  the  color  of  the  evacuation,  we  have  evidence  thereby  of  the 
excess  and  of  the  paucity  of  bile,  sometimes  the  stool  being  of  a  deep 
brown  color,  at  others  almost  as  pale  as  chalk;  ninthly,  the  color 
may  be  changed  by  the  admixture  of  such  substances  as  logwood 
administered  medicinally,  or  blackened  by  steel  medicines,  the  sul- 
phide of  iron  having  been  formed;  and  tenthly,  the  color  is  a  guide 
to  the  detection  of  blood.  Blood  in  the  alvine  discharges  may  be 
only  observable  by  microscopical  examination  ;  but  if  in  larger 
quantity,  the  color  varies  from  the  ordinary  appearance  of  blood  to 
the  black  pitchy  stool  of  melasna,  as  we  have  before  mentioned, 
according  to  the  position  of  the  hemorrhage  in  the  canal.  The 
green  color  of  the  discharges  in  the  severe  diarrhoea  of  children,  we 
believe,  with  Dr.  Golding  Bird,  to  be  altered  blood  from  an  irritated 
and  perhaps  aphthous  surface.  Again,  in  severe  dysentery,  thin 
watery  fluid,  like  the  washing  of  beef,  is  sometimes  discharged,  con- 
sisting of  blood  with  mucus,  and  of  imperfect  epithelial  elements. 
To  these  dysenteric  evacuations  we  shall  have  again  to  refer.  Lastly, 
the  odor  of  the  feces  is  not  altogether  unimportant;  sometimes  they 
are  intolerably  fetid  from  rapid  degenerative  changes,  at  other  times 
they  have  scarcely  any  odor.  In  many  instances  the  microscope 
enables  us  to  detect  an  excess  of  mucus,  the  presence  of  blood,  the 
rapid  discharge  of  epithelial  elements  and  nuclei,  and  other  organic 
and  inorganic  substances,  which  the  unassisted  eye  would  in  vain 
search  for.  We  have  elsewhere  referred  to  the  occasional  presence 
of  phosphatic  crystals  upon  the  mucous  membrane  of  the  intestines, 

1  Dr.  Osborne  "On  the  Examination  of  the  Feces,"  'Dublin  Quart.,'  1853. 


ON    DIARRH(EA.  853 

and  they  are  sometimes  found  in  the  alvine  discharges,  in  simple  as 
well  as  in  typhoid  diarrhoea.  The  presence  of  fatty  matters  in  the 
evacuations  was  first  noticed  by  Dr.  Bright,  in  connection  with  dis- 
ease of  the  pancreas;  and  the  observations  more  recently  made  in 
reference  to  the  physiological  effects  of  the  pancreatic  fluid  have 
directed  increased  attention  to  the  subject.  It  must  not  be  forgotten 
that  we  sometimes  find  oleaginous  substances  discharged  after  the 
administration  of  large  quantities  of  milk  and  of  cod-liver  oil;  thus 
in  one  case  masses  of  fat  as  large  as  filberts  were  sent  to  me  by  a 
patient  affected  with  phthisis,  who  had  partaken  of  milk  very  freely; 
still,  the  observation  has  been  confirmed  by  subsequent  observers, 
that  fatty  matters  are  sometimes  discharged  in  the  alvine  evacua- 
tions in  disease  of  the  pancreas,  and  sometimes  in  extensive  disease 
of  the  mesenteric  gland's. 

The  causes  of  diarrhoea  have  been  partially  referred  to.  1st.  The 
most  common  cause  of  ordinary  diarrhoea  is  exposure  to  cold  and 
wet ;  standing  in  damp  places ;  allowing  the  legs  and  loins  to  become 
damped  and  chilled ;  sitting  down  upon  the  ground,  and  falling- 
asleep  in  the  open  air;  injudicious  bathing;  the  habit  of  leaving  off 
flannel  garments  in  hot  weather,  by  which  perspiration  more  rapidly 
evaporates,  and  the  blood  is  driven  from  the  surface  towards  the 
internal  organs. 

2d.  Improper  and  indigestible  food,  unripe  fruit,  and  an  excess  of 
uncooked  fruit  ;  salads,  pastries,  and  much  that  modern  cookery 
produces,  especially  when  an  excess  in  quantity  is  combined  with  an 
injurious  quality. 

In  infants  a  fertile  source  of  diarrhoea,  often  passing  into  severe 
gastro  enteritis,  is  the  administration  of  unsuitable  food,  the  injuri- 
ous effects  of  which  are  greatly  increased  by  exposure  to  cold.  In 
hospital  and  dispensary  practice,  this  cause  of  disease  is  observed  to 
a  frightful  extent;  at  seven  or  eight  months,  even  while  the  infant 
is,  in  a  great  measure,  nourished  by  the  breast  of  the  mother,  meat, 
raw  vegetables,  and  fruits,  sweets,  almost  ad  libitum,  are  given ;  and 
a  few  months  later  we  often  find,  that  before  the  child  has  the  power 
of  mastication,  the  mother  gives  the  food  of  which  she  herself  par- 
takes, sometimes  adding  malt  liquors  and  ardent  spirits.  The  con- 
sequences of  this  dietary  are  such  as  might  be  anticipated ;  the  food 
passes  onwards  undigested,  severe  gastro-enteritis  is  induced ;  and 
the  malady  is  often  aggravated  by  a  want  of  cleanliness,  and  by 
exposure  to  night  air  and  dampness.  The  mortality  in  London  from 
these  causes  is  exceedingly  great.  In  other  infants  the  food,  although 
in  itself  pToper,  is  unsuited  to  the  condition  then  existing,  and  per- 
petuates diarrhoea ;  or  it  may  be,  that  the  milk  of  the  mother  dis- 
agrees with  the  child,  from  the  impairment  of  her  health.  In  such 
subjects  we  occasionally  find,  that  an  alteration  in  the  character  of 
the  gastric  juice  of  the  infant  leads  to  coagulation  of  the  milk,  and 
to  severe  diarrhoea,  with  colic,  &c.,  the  stools  containing  portions  oi 
curdled  and  undigested  milk,  namely,  oleaginous  matter  mixed  with 
casein.  . 

3d.  Diarrhoea  is  set  up  by  exhaustion,  either  from  want  of  food, 

23 


354  OX    DIARRIKEA. 

starvation  and  its  attendants  of  misery,  or  as  the  consequence  of 
chronic  disease.  This  form  of  diarrhoea  is  sometimes  observed  in 
women  who  have  nursed  their  infants  too  long.  Enfeebled  by  bear- 
ing children  rapidly,  their  strength  is  additionally  taxed  by  nursing 
for  twelve,  fifteen,  or  eighteen  months  without  proper  nourishment 
or  invigorating  air.  The  whole  mucous  membrane  is  affected  ;  the 
nerve  of  organic  life  shows  its  ebbing  powers  ;  the  blanched  cheek, 
the  dilated  pupil,  the  desponding  countenance,  and  impulses  of  a 
mind  verging  on  insanity,  are  symptomatic  of  this  condition.  There 
is  intense  pain  in  the  head,  the  heart  is  enfeebled,  the  pulse  sharp, 
and  sometimes  irregular;  there  is  a  distressing  sensation  of  exhaus- 
tion at  the  scrobiculus  cordis,  with  severe  pain  in  the  back,  and  in 
this  state  a  very  slight  irregularity  of  food  will  sometimes  set  up 
diarrhoea  and  vomiting.  Cancerous  and  strumous  disease  of  the 
mesenteric  glands,  obstruction  of  the  thoracic  duct,  chronic  disease 
of  the  pancreas,  diabetes,  &c.,  sometimes  have  uncontrollable  diar- 
rhoea as  one  of  their  latest  symptoms. 

4th.  Epidemic  causes. — At  some  seasons  of  the  year,  in  our  own 
climate  during  the  spring  and  autumn  months,  diarrhoea  of  varying 
severity  is  set  up,  and  appears  to  arise  from  the  condition  of  the 
atmosphere,  perhaps  from  germs  of  vegetable  or  animal  growth. 

oth.  Endemic  causes  are  more  numerous,  and  with  them  may  be 
classed  the  diarrhoea  arising  from  offensive  drains,  from  decaying 
animal  and  vegetable  matters.  Causes  of  this  kind  operate  with 
greater  severity  upon  the  young  and  enfeebled,  upon  the  strumous 
and  ill-nourished.  Many  infants  are  thus  affected  with  diarrhoea, 
and  with  severe  general  gastro-eteritis.  It  is  now  well  known,  that 
an  impure  water  supply,  especially  if  contaminated  by  sewage,  will 
lead  to  diarrhoea  as  well  as  to  enteric  fever,  and  probably  to  cholera. 
Again,  a  general  dampness  of  locality,  as  from  a  clay  subsoil,  will 
set  up,  or  will  increase  and  perpetuate  diarrhoea.  We  have  wit- 
nessed the  removal  into  dry  bracing  air  followed  by  cessation  of  the 
.  disease,  and  the  return  to  the  same  district  repeatedly  cause  its  re- 
currence. 

6th.  Excessive  secretion  of  bile,  and  other  diseases  of  the  liver,  as 
well  as  disease  of  other  intestinal  glands,  set  up  diarrhoea. 

7th.  Other  causes  are,  tubercular  disease  of  the  mucous  membrane 
of  the  intestine  and  the  mesenteric  glands ;  oedema  and  long-con- 
tinued congestion  of  the  mucous  membrane ;  mental  agitation  and 
fright;  ulceration  of  the  small  and  large  intestine,  as  in  fever, 
phthisis,  &c. ;  cancerous  diseases ;  purpura  and  scurvy ;  large 
draughts  of  water ;  miasmatic  disease ;  poisons. 

Prognosis. — Diarrhoea  is  never  altogether  free  from  danger  in  aged 
persons,  or  in  very  young  children ;  but  the  prognosis  differs  accord- 
ing to  its  cause  and  character.  If  associated  with  chronic  disease, 
or  an  enfeebled  condition  of  the  system,  it  is  often  the  immediate 
precursor  of  death ;  but  when  the  cause  can  be  removed,  and  the 
subject  is  young,  however  severe  the  case  may  be,  we  should  en- 
courage the  prospect  of  recovery.  Many  of  such  cases,  when  ap- 


ON    DIARRHOEA.  355 

parently  quite  in  extremis,  have  gradually  and  almost  miraculously 
recovered. 

The  prognosis  is  unfavorable,  when  diarrhoea  has  been  long  con- 
tinued, and  is  very  severe  in  its  character ;  in  some  of  these  cases 
scarcely  any  treatment  appears  to  arrest  the  purging,  and  the  patient 
gradually  sinks  into  a  typhoid  condition. 

It  may  appear  unnecessary  to  say  any  thing  in  reference  to  the 
diagnosis  of  diarrhoea ;  it  is  well,  always,  if  possible,  to  ascertain 
personally  the  character  of  the  evacuations;  since  there  may  be 
apparent  diarrhcea,  without  the  reality.  I  have  seen  starch  enemata 
used,  when  patients  were  greatly  exhausted,  and  on  inspection,  found 
the  intestine  loaded  with  solid  fecal  matter.  In  spinal  disease,  a  weak 
sphincter  ani  with  involuntary  defecation  is  often  mistaken  for  diar- 
rhoea, and  I  have  known  astringents  continued  for  several  months 
ineffectively,  whereas  rest  to  the  spine  quickly  relieved  the  malady. 
A  hardened  mass  of  feces,  which  the  patient  is  unable  to  expel  from 
the  rectum,  frequently  leads  to  the  repeated  evacuation  of  small 
quantities  of  fluid  feces  or  of  mucus,  which  is  regarded  as  diarrhoea 
or  even  dysentery ;  the  effort  at  expulsion  is  constant  and  painful, 
but  ineffective ;  the  removal  of  the  mass  at  once  checks  the  supposed 
diarrhcea.  Or  again,  in  an  exhausted  state  of  the  system,  or  during 
epidemic  diarrhoea,  a  single  loose  motion  may  require  immediate 
attention  ;  for  the  character  rather  than  the  quantity  should  be  our 
guide.  In  persistent  diarrhcea  it  is  important  always  to  examine  the 
rectum,  for  I  have  frequently  known  cancerous  disease  entirely  over- 
looked from  the  want  of  digital  examination. 

Treatment. — The  primary  object  must  be  to  ascertain  the  character 
of  the  diarrhoea,  and  to  remove,  if  possible,  its  cause.  If  food  be 
improper,  to  change  it,  arid  administer  such  as  shall  be  of  the  least 
irritating  kind.  If  the  air  be  impure,  to  order  removal  to  a  healthy 
atmosphere.  If  the  mucous  membrane  and  the  secretions  be  dis- 
ordered, to  try  and  restore  them  to  a  healthy  state.  To  check  the 
diarrhcea  by  various  astringents  and  by  rest. 

Warmth. — Warm  baths,  warmth  applied  to  the  feet,  and  flannel  to 
the  abdominal  parietes,  a  warm  but  pure  air,  &c.,  assist  in  checking 
many  of  the  simpler  forms,  and  in  diminishing  those  arising  from 
chronic  disease.  Local  warmth  may  be  attained  by  the  application 
of  a  hot  fomentation,  or  poultice  to  the  abdomen,  or  by  such  rube- 
facients  as  a  mustard  poultice,  or  turpentine  embrocation. 

Food.— In  diarrhoea  the  least  irritating  and  the  most  easily  diges- 
tible kinds  of  nourishment  are  advisable.  Many  of  the  forms  of 
amylaceous  aliment,  arrowroot,  sago,  are  of  this  kind,  and  may  be 
given  made  with  milk  ;  these  are  in  themselves  soothing  applications 
to  irritated  mucous  membranes,  whilst  they  serve  as  nourishment  to 
the  system.  Milk,  rice,  soaked  bread  and  toast,  lightly-boiled  pud- 
dings of  flour  and  eggs,  &c.,  may  be  also  taken  with  advantage,  and 
in  chronic  diarrhcea  suet  and  milk  is  often  of  great  benefit. 

The  avoidance  of  stimulants,  of  rich  and  greasy  food,  of  highly 
seasoned  dishes,  of  vegetables,  especially  when  uncooked,  of  fruits, 
&c.,  is  essential ;  and  it  is  well  in  many  cases  to  abstain  for  a  short 


356  ON    DTARBIKEA. 

time  from  solid  animal  food  altogether.  The  forms  of  animal  food 
•which  are  most  easily  digestible  are  chicken,  sweetbread,  and  some 
forms  of  fish,  as  sole,  cod,  and  whiting;  then  venison,  mutton,  and 
beef;  but  much  depends  on  the  mode  in  which  these  viands  are 
dressed.  When  dried,  salted,  and  cold,  they  require  a  much  longer 
period  for  their  digestion,  and  portions  often  pass  into  the  intestine 
undissolved.  Beef- tea  sometimes  appears  to  increase  diarrhoea,  when 
veal  and  mutton  broth  can  be  taken  with  benefit. 

Rest,  and  the  avoidance  of  muscular  excitement  and  sudden  move- 
ments, are  very  important  in  checking  diarrhoea ;  and  in  many 
instances,  especially  in  severe  cases,  a  recumbent  posture  should  be 
maintained.  In  the  erect  position  the  gravitation  of  fluids  increases 
their  rapid  movement  over  the  irritated  mucous  membrane. 

Pure  and  dry  air  is  very  desirable ;  many  patients  at  once  recover 
when  removed  from  a  damp  atmosphere  to  a  dr,y  and  bracing  one ; 
and  when  the  contamination  of  decomposing  animal  and  vegetable 
substances  is  setting  up  the  disease,  removal  is  still  more  important, 
and  is  often  essential  to  permanent  restoration.  In  miasmatic  dis- 
tricts, diarrhoea  may  not  only  be  rendered  paroxysmal,  but  be  per- 
petuated by  the  marsh  poison. 

Many  cases  of  diarrhoea  will  be  cured  by  this  attention  to  warmth 
and  diet,  to  rest  and  pure  air;  but  other  means  often  promote  the 
comfort  and  favor  the  restoration  to  health. 

If  the  large  intestine,  and  especially  the  rectum,  be  affected,  much 
benefit  is  derived  from  enemata.  These  are  composed  of  various 
ingredients,  simple  starch,  thin  gruel,  and  barley-water ;  and  to  these 
we  may  add  tincture  of  opium  and  biborate  of  soda.  Or  they  may 
be  made  astringent,  as  decoction  of  oak  bark  with  tragacanth,  or 
glycerine  of  tannin  with  water;  or  a  very  dilute  solution  of  nitrate 
of  silver  may  be  used  ;  an  infusion  of  ipecacuanha  has  been  favorably 
recommended  as  an  injection  by  Boudin  and  Chouppe. 

To  restore  the  diseased  mucous  membrane  and  to  correct  secretions. — 
The  alkalies  are  of  very  great  service  in  diminishing  congestion,  as 
well  as  in  rendering  the  secretions  less  irritating.  Solution  of  potash, 
lime-water,  chalk,  some  salines,  as  chlorate  of  potash,  bicarbonate  of 
potash,  and  nitrate  of  bismuth,  act  in  this  manner. 

When  the  hepatic  secretions  are  disordered,  as  shown  by  furred 
tongue,  and  pale  evacuations,  the  moderate  use  of  mercurials  is  of 
value,  as  gray  powder  or  calomel^  combined  with  Dover's  powder, 
with  soda  or  with  opium;  but  we  should  strongly  urge  that  mercu- 
rials be  very  carefully  administered,  because  in  many  forms  of  diar- 
rhoea they  tend  greatly  to  aggravate  the  disease.  It  is  only  in  some 
cases,  even  with  a  foul  tongue,  and  deficient  hepatic  secretions,  that 
we  would  recommend  their  use. 

Demulcents. — These  act  by  directly  sheathing  the  mucous  mem- 
brane ;  the  most  important  are  those  mentioned  as  food,  but  others 
are  of  considerable  utility,  as  acacia,  tragacanth,  linseed,  liquorice, 
glycerine,  spermaceti,  &c. 

Castor-oil,  Linseed-oil. — These  are  of  great  value,  when  improper 
food,  retained  secretions  and  scybala  irritate  the  alimentary  canal. 


ON    DIARRH<EA.  357 

They  are  combined  with  great  advantage  with  the  compound  tincture 
of  rhubarb,  and  sometimes  with  a  small  dose  of  opium,  "lv  or  x. 
These  remedies  are  of  most  service  in  some  forms  of  dysenteric 
diarrhoea,  when  scybala  irritate  the  mucous  membrane. 

Ipecacuanha  is  a  remedy  which  acts,  apparently,  on  all  the  mucous 
membranes,  and  is  as  valuable  in  disease  of  the  alimentary  as  of  the 
respiratory  mucous  membrane.  Ipecacuanha  not  only  increases 
the  quantity  of  mucus  but  it  mitigates  inflammatory  congestion.  It 
is  of  great  service  in  the  dysenteric  diarrhoea  of  adults,  and  equally 
so  in  the  diarrhoea  of  infants.  In  the  former,  Dover's  powder  is 
a  valuable  form  for  its  administration,  or  the  ipecacuanha  may  be 
combined  with  astringents,  as  in  the  compound  infusion  of  krarneria,1 
and  the  compound  logwood  mixture  of  the  Guy's  Pharmacopoeia,  or 
it  may  be  administered  alone  as  in  the  treatment  of  pure  dysentery. 

Astringents  and  Desiccants. — These  may  be  divided  into  several 
classes.  The  saline,  as  chalk  ;  the  vegetable,  as  tannic  and  gallic  acids, 
krameria,  kino,  catechu,  logwood,  Indian  bael,  cusparia,  opium;  me- 
tallic, as  sulphate  of  copper,  acetate  of  lead,  nitrate  of  silver,  nitrate 
of  bismuth,  &c. 

Opium  acts  not  only  as  an  astringent,  but  also  as  a  narcotic ;  it 
diminishes  the  secretion  from  the  mucous  membrane,  and  the  peri- 
staltic movement  of  the  intestine,  and  it  relieves  the  pain  of  colic. 
It  is  of  great  value  in  diarrhoea,  and  may  be  combined  with  other 
remedies,  as  with  chalk  and  ipecacuanha;  but,  when  irritating  in- 
gesta  and  disordered  secretions  perpetuate  diarrhoea,  opium  and 
astringents  are  not  appropriate  remedies.  When  the  disease  is 
chronic,  opium  may  be  given  with  the  more  active  vegetable  astrin- 
gents, catechu,  krameria,  and  logwood,  and  sometimes  very  advan- 
tageously with  quinine. 

The  metallic  astringents  are  combined  in  a  similar  manner  with 
opium  and  ipecacuanha,  but  are  more  frequently  used  in  chronic 
dysentery,  and  in  tubercular  ulceration  of  the  intestine,  than  in  sim- 
ple diarrhoea. 

Mineral  Acids. — Much  has  been  written  upon  the  use  of  dilute 
sulphuric  acid  in  diarrhoea;  and  its  use  has  certainly  been  attended 
with  benefit,  although  not  to  the  extent  we  were  led  to  suppose. 
Botli  dilute  sulphuric  acid,  and  dilute  nitric  acid,  are  of  value  after 
the  more  severe  symptoms  have  passed  off;  they  act  at  first  possibly 
by  checking  chemical  and  fermentative  changes,  and  afterwards  as 
tonics  to  the  relaxed  mucous  membrane.  Combined  with  slightly 
astringent  and  mucilaginous  tonics,  as  with  cusparia  and  simaruba, 
or  with  calumba  root  and  elm  bark,  they  are  of  great  service  in 
some  cases. 

When  there  is  much  pain,  we  may  associate  narcotics  with  other 
remedies  before  mentioned.  Spirit  of  chloroform  and  spirit  of  cam- 
phor in  small  doses  sometimes  afford  great  relief,  so  also  the  tincture 
of  henbane;  in  other  cases,  simple  carminative  medicines  are  suffi- 

1  Infusum  Krameriae  compositum.     Infusion  of  Rhatany  Root  fl..5xj ;  Ipecacuanha 
Wine  3'Vj  Tincture  of  Catechu  3iy- 


358  ON    DIARRHCEA. 

cient  to  relieve  the  pain,  as  ginger,  cardamoms,  &c.,  especially  where 
the  diarrhoea  is  associated  with  flatulent  colic. 

In  the  colliquative  diarrhoea  of  weaned  children,  Dr.  I.  F.  Weisse 
has  strongly  advocated  the  administration  of  raw  meat,  scraped  and 
reduced  to  a  pulp,  as  we  have  previously  mentioned  in  the  remarks 
on  enteritis. 

Leeches. — The  application  of  leeches  to  the  anus  is  a  remedy  which 
greatly  relieves  inflammatory  congestion  of  the  mucous  membrane 
of  the  large  intestine,  but  it  is  one  which  we  should  scarcely  recom- 
mend, unless  the  disease  assume  a  severe  and  dysenteric  character. 

Suppositories,  composed  of  the  compound  soap  pill  or  morphia,  are 
often  of  great  service  when  there  is  distressing  tenesmus  which  dis- 
turbs the  rest  of  the  patient;  and  when  it  is  undesirable  to  admin- 
ister an  opiate  by  the  mouth,  or  inconvenient  to  use  an  enema. 
Tannin  may  also  in  this  way  be  conveniently  used,  so  also  bismuth. 

In  chronic  mucous  discharge  from  the  bowels,  we  must  first  seek 
to  remove  the  disease  of  the  liver,  if  such  exist,  by  mild  alteratives, 
by  taraxacum,  and  by  nitro-muriatic  acid.  These  remedies,  also, 
assist  in  relieving  the  chronic  congestion  and  inflammation  of  the 
intestine,  and  are  more  effective  than  astringents.  It  is  well,  how- 
ever, to  be  assured  that  no  polypoid  growth,  nor  disease  of  the 
rectum  and  sigmoid  flexure,  is  setting  up  the  disease. 

If  astringents  be  required  in  these  instances,  the  oxide  and  nitrate 
of  silver,  sulphate  of  copper  with  opium,  or  the  vegetable  astringents 
just  mentioned,  may  be  used;  and  as  enemata,  glycerine  of  tannin 
diluted  with  water,  the  solution  of  nitrate  of  silver  (gr.  x-xv  to  Oj1), 
the  infusion  of  quassia,  the  decoction  of  oak  bark,  and  the  decoction 
of  poppies  with  or  without  the  addition  of  borax,  may  be  employed 
with  advantage. 

In  the  treatment  of  choleraic  diarrhoea,  rest  in  the  recurnl)ent 
position,  warmth  to  the  abdomen  and  the  feet,  and  gentle  friction, 
if  muscular  spasm  distress  the  patient,  are  valuable  remedies.  A 
full  dose  of  chalk  and  opium  with  catechu  and  aromatic  spirit  of 
ammonia  should  be  given,  and  repeated  in  two  or  three  hours,  if 
necessary.  Demulcent  nutriment,  as  mutton  broth  and  arrowroot, 
may  be  allowed:  and  if  vomiting  supervene,  ice  or  cold  water  will 
be  beneficial.  Dilute  sulphuric  acid  has  been  sometimes  used  with 
great  advantage,  and  by  some  calomel  has  been  freely  given  in  these 
cases,  especially  when  vomiting  has  come  on.  When  the  collapse 
of  true  cholera  has  attacked  the  patient,  general  experience  does  not 
favor  the  free  use  of  either  opium  or  brandy;  but  to  enter  fully  into 
the  treatment  of  cholera  is  foreign  to  our  purpose. 

The  following  cases  of  diarrhoea  are  of  considerable  interest:— 

CASE  CXXV.  Inanition.  Diarrhoea — John  M — ,  aet.  26,  was  admitted 
into  Guy's  Hospital  Dec.  17th,  1856,  and  died  Dec.  20th.  He  had  been  a 
sailor,  and  stated  that  he  had  had  dysentery,  but  this  was  not  satisfactorily 
ascertained,  on  account  of  his  prostrate  condition.  It  appeared  that  lie  had 
been  on  board  an  American  vessel  from  China  to  Liverpool,  and  arrived  at 

1  Trousseau. 


OX    DIARRHCEA.  359 

the  latter  place  on  December  6th  ;  he  then  came  up  to  London.  He  informed 
the  nurse  that  there  had  been  a  mutiny  on  board,  and  that  he  had  been  put 
in  irons  in  the  hold.  He  was  in  the  most  emaciated  state ;  the  voice  was 
scarcely  perceptible ;  the  pulse  was  exceedingly  compressible,  and  the  tongue 
and  mouth  presented  yellowish-white  aphthous  patches  ;  he  had  no  vomiting, 
but  the  stools  escaped  from  him,  and  were  white  and  very  offensive ;  the 
respiration  was  easy,  and  the  mind  perfectly  conscious.  Milk  was  ordered. 
The  following  day  he  was  better,  but  sank  on  the  third  day  after  admission, 
and  was  sensible  till  nearly  the  last. 

Inspection,  December  22,  1856 — There  were  ecchymoses  on  both  thighs, 
and  old  cicatrices  on  the  wrist  and  leg.  The  brain  was  less  firm  than  normal ; 
the  lungs  were  collapsed  and  healthy.  The  heart  was  small.  The  liver  was 
healthy.  The  gall-bladder  was  not  distended,  and  the  spleen  and  kidneys 
were  healthy.  The  stomach  presented  gastric  solution  at  the  cardiac  portion. 
The  small  intestines  were  healthy.  The  large  intestine  was  throughout  of  a 
gray  color,  and  was  filled  with  dry,  white  feces.  At  the  root  of  the  mesen- 
tery were  several  white  strumous  masses  in  the  glands,  but  it  could  not  be 
found  that  the  thoracic  duct  was  obstructed.  The  urinary  bladder  was  dis- 
tended. 

This  case  presents  us  with  a  well-marked  instance  of  a  man  dying 
from  the  effect  of  starvation.  The  diarrhoea  was  probably  the  result 
of  want  of  nourishment,  of  good  air,  and  of  light,  &c.;  so  that  sup- 
plies having  been  cut  off  and  the  conditions  necessary  for  reparation 
excluded,  the  whole  body  wasted,  and  the  spark  of  life  graduallv 
expired. 

CASE  CXXVI.  Chronic  Diarrhoea.  Hysteria.  Great  Relief  from 
Tincture  of  Iron — Georgiana  B — ,  aet.  40,  a  single  woman,  who  had  resided 
in  the  Commercial  Road,  and  had  supported  herself  by  her  needle,  applied  at 
Guy's  Hospital  May  23d,  1860,  and  was  admitted  under  my  care.  She  had 
suffered  from  uterine  ulceration.  During  eighteen  months  she  had  been 
affected  with  diarrhoea,  and  when  she  had  mental  anxiety  the  disease  increased 
in  severity.  The  slightest  exertion  produced  perspiration.  She  was  a  tall 
woman,  extremely  nervous,  the  eyes  sunken,  the  countenance  dejected.  The 
heart  and  lungs  were  normal.  She  complained  of  great  pain  in  the  abdomen, 
on  the  right  side  below  the  liver,  in  the  region  of  the  ascending  colon  ;  there 
was  tympanitic  distension  in  the  same  region ;  the  bowels  were  opened  six 
times  in  twenty-four  hours,  but  there  was  no  evidence  that  blood  had  been 
passed.  She  had  not  taken  meat  during  several  months  Astringents  of 
different  kinds  were  administered  and  enemata  used,  with  only  partial  relief, 
till  the  tincture  of  iron  was  given  persistently  for  several  weeks.  The  diar- 
rhoea then  subsided,  and  she  left  the  hospital  convalescent,  stating  that  she 
had  not  been  so  well  for  eight  years. 

This  case  appeared  to  be  one  of  passive  mucous  diarrhoea  in  a 
very  hysterical  subject,  and  the  uterine  irritation  had  tended  to  per- 
petuate the  disease.  Astringents  were  less  efficacious  than  prepara- 
tions of  steel,  which  diminished  the  nervous  irritability  and  gave 
tone  and  strength  to  the  whole  system.  The  regulated  and  more 
generous  diet  which  was  given  must  not  be  overlooked ;  and  by  per- 
suasive measures  she  was  induced  to  take  a  meat  diet,  which  lessened 
the  fluid  contents  of  the  colon,  and  thereby  increased  the  consistence 
of  the  alvine  discharges. 


360 


CHAPTER    XII. 

ON  DYSENTERY  AND  CATARRHAL  INFLAMMATION  OF  THE  COLON. 

NUMEROUS  authors,  as  Sydenham,  Annesley,  Parkes,  Ballingall, 
Sir  J.  McGrigor,  and  Morehead,  have  described  the  terrible  forms  of 
this  disease  as  they  are  manifested  in  tropical  climates,  and  in  mili- 
tary campaigns,  and  as  formerly  seen  in  England.  In  our  own 
country,  however,  dysentery  has  very  much  diminished  in  severity 
and  in  frequency,  so  that  in  its  acute  form  it  is  rarely  seen  amongst 
us,  unless  contracted  in  foreign  climes,  and  then  brought  to  our 
shores.  Still  true  dysentery  occurs  more  commonly  than  some  of 
very  great  experience  will  admit ;  sometimes  it  is  the  only  disease 
from  which  the  patient  suffers,  and  is  quickly  fatal ;  or  it  is  found 
in  association  with  a  general  inflammatory  condition  of  other  mucous 
membranes ;  or  lastly,  it  aggravates  varied  forms  of  chronic  disease, 
or  it  causes  their  sudden  termination. 

Particular  localities  and  periods  of  the  year  cause  the  manifesta- 
tion of  this  disease,  and  its  complication  with  others  in  a  very 
marked  degree.  This  fact  is  shown  by  the  observations  of  Dr. 
Latham  and  Dr.  Baly  at  the  Millbank  Prison  ;  and  the  greater 
humidity  of  the  atmosphere  is  probably  the  reason  of  the  more  fre- 
quent occurrence  of  dysentery  in  the  hospitals  in  Southwark  than 
elsewhere  in  London.  When  other  diseases  are  complicated  by  dys- 
entery a  very  important  consideration  is  introduced  into  their  prog- 
nosis and  treatment ;  thus  incipient  phthisis  may  become  altogether 
hopeless,  and  in  a  very  short  time  fatal,  not  from  the  severity  of  the 
pulmonary  affection,  nor  from  tubercular  disease  of  the  intestines, 
but  from  acute  inflammation  of  the  mucous  membrane  of  the  colon. 

Abercrombie  defined  diarrhoea  as  purging,  arising  from  irritating 
substances  in  the  canal,  and  from  secretions  poured  into  it ;  and  dys- 
entery, as  acute  inflammation  originating  in  the  mucous  membrane 
of  the  large  intestine.  This  distinction  is  probably,  to  a  considerable 
extent,  correct ;  but  some  forms  of  disease  usually  considered  as 
diarrhoea,  arise  from  catarrhal  inflammation  of  the  colon  and  small 
intestine,  and  after  death  may  present  scarcely  any  trace  of  abnormal 
change.  Dysentery  is  generally  limited  to  the  colon,  and  when 
severe  the  disease  rapidly  passes  into  ulceration  and  sloughing, 
unless  from  its  extent,  or  the  previous  condition  of  the  patient,  it 
prove  fatal  at  an  anterior  stage,  as  in  several  of  the  fatal  cases  re- 
corded in  this  chapter,  which  terminated  before  extensive  ulceration 
had  taken  place. 


DYSENTERY    AND    CATARRHAL    INFLAMMATION    OF    COLON.      361 


DYSENTERY. 

Dysentery  does  not  embrace  every  form -of  inflammation  of  the 
mucous  membrane  of  the  colon,  and  we  would  distinguish  it  from 
catarrhal  inflammation,  confining  the  term  dysentery  to  that  more 
severe  inflammation  which  rapidly  passes  into  ulceration.  In 
catarrh  the  condition  of  the  mucous  membrane  is  altered,  as  we 
described  in  speaking  of  enteritis,  the  membrane  is  congested,  and 
the  secretion  is  at  first  checked,  afterwards  it  becomes  excessive. 
This  state  may  soon  subside,  or  it  may  continue  for  months,  and 
even  for  years.  Like  dysentery  it  may  be  brought  on  by  endemic 
causes,  by  cold  and  wet,  and  by  unwholesome  diet ;  at  the  commence- 
ment of  a  dysenteric  attack  the  symptoms  may  at  first  be  those  of 
acute  catarrh  of  the  colon,  and  on  the  subsidence  of  the  dysenteric 
ulceration,  troublesome  catarrh  of  the  bowels  may  persist  for  a 
lengthened  period. 

Dr.  Lyon,  in  his  Crimean  report,  has  divided  dysentery  into  two 
forms,  the  exudative  and  the  follicular.  The  former  is,  however, 
probably  the  earlier  stage,  or  that  preceding  ulceration  and  slough- 
ing. The  cases  which  have  come  under  my  own  observation  may 
be  divided,  practically,  into  three  classes : — " 

1.  Those  instances  in  which  acute  disease  of  the  colon  is  the  pri- 
mary disease,  and  sometimes  it  terminates  fatally  in  a  short  time. 

2.  Those  cases  in  which  dysentery  is  associated  with  inflammation 
of  other  membranes  and  organs,  as  when  bronchitis,  laryngitis,  and 
pneumonia  arise  at  the  same  time,  and  are  produced  apparently  by 
the  same  cause  as  the  disease  of  the  intestine ;  in  some  instances  the 
disease  is  closely  allied  to  pyaemia. 

3.  Those  cases  in  which  inflammation  of  the  colon  has  hastened 
the  fatal  termination  of  other  more  chronic  disease. 

Morbid  anatomy. — The  dysenteric  process  is  well  described  by 
Rokitansky,  who  divides  it  into  four  stages,  and  considers  that  it 
consists  in  inflammation  of  the  mucous  membrane  of  the  colon,  ter- 
minating in  severe  cases  in  sphacelus.  Dr.  Parkes  believes  that,  in 
true  dysentery,  ulceration  is  always  present,  and  attaches  great  im- 
portance to  the  affection  of  the  glands ;  whilst  Dr.  Baly  describes  the 
process  as  sloughing,  rather  than  ulceration.  Are  we  then  to  look 
upon  inflammation  of  the  colon,  in  which  there  is  no  destruction  of 
the  mucous  membrane,  as  true  dysentery  ?  It  will  be  generally  ac- 
knowledged, that  death  may  take  place  prior  to  the  ulceration  or 
sloughing,  although  we  rarely,  if  ever,  find  the  mucous  membrane 
entire ;  it  is  probable  that  the  diseased  condition  is  closely  allied  to 
that  of  the  pharynx  in  diphtheria;  and,  that  in  severe  cases  the 
membrane  rapidly  sloughs,  without  anctecedent  ulceration. 

In  the  earlier  stage  of  dysentery,  the  mucous  membrane  becomes 
injected,  oedematous,  and  thickened ;  the  mucus  is  scanty,  and  the 
feces  become  adherent ;  this  condition  may  be  universal  in  the  colon, 
or  limited  to  the  rectum,  to  the  sigmoid  flexure,  or  to  the  caecum.  The 
solitary  glands  will  be  found  to  be  distinct,  prominent  and  enlarged. 

The" secretion  from  the  membrane  then  becomes  further  changed, 


362  ON    DYSENTERY    AND 

and  a  thin  exudation,  consisting  of  epithelium  with  a  considerable 
quantity  of  granular  amorphous  matter,  coats  the  intestine.  This 
exudation  is  found  in  patches,  or  in  lines,  or  it  is  spread  generally, 
upon  the  surface.  It  has  been  described  as  dipping  into  the  follicles; 
an  appearance  which  I  have  myself  observed,  and  it  may  also  be 
seen  closely  incorporated  with  the  surface  of  the  membrane,  so  that 
it  can  only  be  separated  by  considerable  violence.  The  color  of  the 
exudation  is  generally  of  a  greenish  yellow  ;  but  it  varies  somewhat 
according  to  the  character  of  the  feces.  On  scraping  off'  the  effusion 
from  the  surface,  the  membrane  beneath  is  found  intensely  congested, 
and  often  superficially  ulcerated ;  oj,  there  may  be  merely  minute 
circular  patches  of  ulceration,  with  portions  of  the  false  membrane 
adhering  at  that  part.  This  tendency  to  ulcerate,  or  to  slough, 
resembles  diphtheritic  disease  in  the  pharynx  and  nares ;  but  the 
character  of  the  false  membrane  in  the  throat  is  more  fibrinous  than 
that  developed  in  the  intestine.  The  muscular  coat  of  the  colon 
appears  thickened  in  this  stage  of  dysentery,  probably  because  it  is 
contracted ;  and  the  submucous  cellular  tissue  is  often  whitish  and 
distinct  from  inflammatory  oedema.  Dr.  Baly,  whilst  describing  this 
epithelial  degeneration,  states,  that  in  most  cases  these  minute  ad- 
herent coverings  on  the  surface  of  superficial  erosions,  or  small  ulcers, 
consist  of  thin  sloughs  of  the  'mucous  membrane.  He  believes,  that 
in  all  cases,  the  destruction  of  the  mucous  membrane  consists  in  a 
process  of  mortification  and  sloughing,  and  not  of  simple  ulceration  ; 
and  that  the  disease  commences  in  the  solitary  glands  of  the  intes- 
tines. Other  parts,  however,  beside  the  solitary  glands,  are  found 
to  be  diseased ;  but  whether  primarily  or  by  extension,  is  matter  of 
opinion.  Many  instances  of  diarrhoea  are  observed,  in  which,  after 
death,  the  solitary  glands  are  found  enlarged,  or  minute  points  of 
ulceration  are  presented ;  the  whole  colon  may  be  studded  over  with 
minute  ulcers,  arising  apparently  in  the  glands,  as  is  well  shown  in  a 
specimen  in  the  Guy's  Museum,  to  which  reference  has  before  been 
made.  Dr.  Baly  would  probably  consider  these  to  be  instances  of 
the  dysenteric  process  in  its  mildest  form,  and  that  in  other  instances, 
previously  alluded  to,  more  acute  changes  had  spread  from  the  glands 
to  the  general  surface  of  the  membrane. 

Dr.  Morehead  has  in  some  cases  observed  diphtheritic  membrane 
effused  in  dysentery,  and  believes  that  the  mucous  follicles  are  more 
frequently  affected  than  the  solitary  glands.1 

In  the  third  stage,  we  find  ulceration,  sometimes  merely  as  minute 
circular  ulcers,  but  generally  of  a  more  extensive  character;  the 
ulcers  are  often  oval  in  form,  and  placed  in  the  transverse  axis  of 
the  intestine ;  and  their  edges  are  raised  and  injected,  irregular  and 
undermined ;  and  their  base  is  formed  by  the  cellular  or  muscular 
coats.  These  ulcerations  gradually  extend  so  as  to  coalesce,  till  at 
last  nearly  the  whole  of  the  mucous  surface  is  destroyed,  except  here 
and  there  in  prominent  isolated  portions,  which  become  intensely 
congested,  and  resemble  polypoid  growths.  In  severe  cases  the 

Morehead,  '  On  Diseases  of  India.' 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  363 

whole  colon,  from  the  caecum  to  the  rectum,  is  in  this  condition ;  or 
greater  spaces  intervene  between  the  ulcers,  which  are  only  found 
in  the  rectum,  or  in  the  sigmoid  flexure,  or  in  the  csecum ;  but  gene- 
rally the  rectum  and  the  sigmoid  flexure  are  the  parts  most  severelv 
implicated.  It  sometimes  happens,  that  the  ulceration  extends 
through  the  muscular  and  the  peritoneal  coat,  leading  to  fatal  peri- 
tonitis from  perforation,  but  this  is  a  rare  occurrence ;  or,  the  coats 
of  the  intestine  become  sinuous  abscesses,  so  that  on  dividing  a 
prominent  portion  of  mucous  membrane  between  two  ulcers,  several 
drachms  of  pus  escape.  This  extensive  suppuration  is  very  different 
from  the  small  local  collections  of  pus,  which  sometimes  form  in  the 
substance  of  the  mucous  membrane  after  follicular  and  glandular  in- 
flammation, where  small  eminences  about  half  an  inch  in  diameter 
are  observed,  covered  by  thin  layers  of  mucous  membrane.  The 
latter  is  a  less  general  and  less  severe  form  of  inflammation  of  the 
colon,  but  one  which  I  have  several  times  observed. 

The  liver  is  generally  found  to  be  congested,  and  the  gall-bladder 
to  be  partially  distended  either  with  inspissated  bile  or  orange-colored 
mucus.  The  mesenteric  glands  are  often  somewhat  congested  :  and 
in  some  instances  the  ileum  and  the  jejunum  are  both  diseased,  be- 
coming intensely  injected,  partially  ulcerated,  and  covered  with 
diphtheritic  membrane ;  Peyer's  glands  are  also  found  to  be  con- 
gested and  enlarged;  although  never  raised  and  infiltrated  with 
deposit,  as  in  enteric  fever. 

Dr.  Morehead  gives  an  instance  of  fecal  abscess,  in  the  right  iliac 
fossa,  from  perforation  of  the  cascum  in  dysentery. 

If  the  acute  symptoms  have  subsided,  the  injection  is  less  deep  in 
color,  and  often  becomes  gray;  the  edges  of  the  ulcers  assume  a 
rounded  and  less  prominent  aspect;  their  surface  has  a  smooth  and 
fibrous  appearance;  ulcerative  action  has  been  checked,  and  cicatri- 
zation has  commenced.  The  healing  process  may  go  on,  so  that  the 
cicatrix  has  an  irregular  and  puckered  appearance.  The  base  of  the 
cicatrix  is  formed  by  fibro-cellular  tissue,  but  the  gland  structure  is 
not  reproduced.  The  contraction  of  the  cicatrix  sometimes  produces 
considerable  constriction  of  the  intestine,  and  occasionally  tends  to 
fatal  obstruction.  Very  frequently  above  the  cicatrix  all  the  coats 
become  hypertrophied,  showing  that  there  has  been  much  impedi- 
ment. Dr.  WilKs  has  informed  me  of  a  case,  and  there  are  many 
others  now  on  record,  in  which  the  cicatrix  presented  a  growth  at  its 
margin,  evidently  of  a  carcinomatous  character,  indicating  a  greater 
tendency  to  heterologous  growth  in  the  new  than  in  a  normal  tissue. 

In  a  fourth  stage  of  dysentery  the  mucous  membrane  presents  a 
gray,  ashy  appearance,  and  considerable  portions  of  it  constitute 
ragged  and  semi-detached  sloughs. 

Dysentery  often  terminates  in  complete  recovery;  at  other  times 
death  quickly  supervenes  from  the  severity  of  the  disease ;  or, 
thirdly,  it  passes  into  a  chronic  state,  which  may  continue  with  inter- 
missions for  several  years. 

Other  seqmlse  of  dysentery  are — perforation  of  the  intestine  and 
fatal  peritonitis;  fecal  abscess;  gradually  increasing  exhaustion  from 


364 


ON    DYSENTERY    AND 


the  destruction  of  the  mucous  membrane,  and  continued  purging; 
constipation,  arising  from  the  contraction  of  cicatrices  leading  to  a 
very  troublesome  and  irregular  condition  of  the  bowels,  and  some- 
times to  fatal  obstruction;  pyasmia  and  suppuration  in  the  substance 
of  the  liver,  from  the  absorption  of  pus,  as  described  by  Dr.  Budd, 
in  his  work  on  'Diseases  of  the  Liver.'  This  last  result  I  have  only 
once  observed  at  Guy's,  in  simple  English  dysentery,  which  is  nearly 
in  accordance  with  the  experience  of  Dr.  Baly,  at  the  Millbank  Peni- 
tentiary, and  shows  that  whilst  the  disease  may  be  the  same  in  its 
general  character  and  pathology  with  tropical  dysentery,  there  is 
some  modifying  cause. 

It  must  be  borne  in  mind,  however,  that  abscess  in  the  liver  may 
occur  without  dysentery,  and  that  the  abscesses  which  are  generally 
found  in  pyaemia  are  different  both  in  character  and  in  position  from 
those  observed  in  connection  with  tropical  disease  and  with  dysen- 
tery; in  ordinary  pyaemia  the  abscesses  are  small,  peripheral  and 
often  numerous,  in  the  hepatic  abscess  found  with  dysentery,  the 
abscess  is  often  larger  and  it  may  be  single;  so  also  in  the  abscesses 
following  tropical  hepatitis.  Dr.  Mayne  in  a  very  interesting  article 
in  the  Dublin  'Quarterly  Review,'  also  mentions  a  state  resembling 
phlegmasia  dolens  as  the  occasional  sequence  of  dysentery,  and 
speaks  of  spontaneous  salivation  as  sometimes  supervening  after  the 
disease. 

Symptoms. — A  sensation  of  coldness  in  the  loins,  chilliness,  or 
actual  rigor,  is  followed  by  a  loose  evacuation  from  the  bowels;  this 
alvine  discharge  is  repeated,  and  the  evacuations  become  scanty,  and 
are  often  accompanied  with  tenesmus,  or  a  forcing  sensation  as  if 
the  intestine  retained  its  fecal  contents.  With  this,  there  may  be 
slight  pain  or  soreness  in  the  iliac  region  or  position  of  the  trans- 
verse colon,  and  even  severe  griping;  febrile  disturbance  supervenes, 
and  the  tongue  has  a  whitish  fur,  or  is  injected  at  the  tip  and  edges, 
but  the  latter  symptoms  are  often  absent.  In  mild  cases  the  ener- 
gies and  mental  activity  are  unimpaired,  but  the  face  becomes  pallid, 
and  the  strength  is  not  equal  to  accustomed  duty. 

This  condition  may  continue  for  several  days,  the  patient  becoming 
more  feeble,  the  motions  watery,  or  they  contain  mucus  and  blood, 
and  scybala  are  passed  with  pain.  The  countenance  becomes  hag- 
gard, and  expressive  of  distress,  the  skin  clammy,  and  the  pulse 
compressible;  the  abdomen  is  collapsed,  and  tolerant  of  pressure; 
.  the  pain  is  paroxysmal,  and  occasionally  very  severe,  and  vomiting 
sometimes  supervenes. 

If  the  disease  continue  unchecked,  the  strength  fails,  the  pulso  is 
rapid  and  compressible,  and  the  eyes  are  sunken;  the  tongue  is 
brown,  or  it  is  dry  and  cracked;  the  motions  are  passed  involun- 
tarily, and  often  are  of  a  greenish  color,  or  they  resemble  the  washing 
of  meat;  the  lower  extremities  are  cold,  and  the  hands  and  face  are 
covered  with  a  clammy  sweat;  occasional  cramps,  with  hiccough 
and  subsultus  tendinum,  come  on;  the  patient  is  sensible,  but  speaks 
in  a  feeble  tone  of  voice,  and  at  last  dies,  more  suddenly,  perhaps, 
than  those  around  him  had  anticipated. 


CATARRIIAL    INFLAMMATION  'OF    THE    COLON.  365 

These  symptoms  may  only  extend  over  a  very  few  days  or  hours, 
and  sometimes  are  accompanied  with  much  febrile  disturbance,  with 
tenderness  of  the  abdomen,  and  with  a  furred  and  brown,  or  red,  dry 
and  glazed  tongue.  If  the  severity  of  the  disease  abate,  the  bowels 
become  more  composed,  and  the  patient  rallies;  or  the  diseased  con- 
dition returns  with  greater  severity;  for  the  first  exhaustion  is 
scarcely  recovered  from  before  the  strength  is  still  further  reduced, 
and  in  this  way  the  malady  may  extend  over  weeks,  or  months! 
The  patient  then  has  a  peculiar  and  characteristic  appearance;  he 
is  much  emaciated;  he  has  a  sallow  complexion;  his  mind  is  active, 
but  physical  strength  fails  gradually,  till  at  last  he  is  obliged  entirely 
to  take  to  his  bed  from  a  sense  of  utter  prostration. 

In  the  dysentery  of  the  tropics,  or  the  equally  severe  disease  ob- 
served in  the  hardships  of  war  and  after  famine,  the  prostration  is 
more  rapid,  the  disease  more  quickly  fatal,  and  in  some  instances 
has  been  accompanied  with  violent  delirium. 

In  reviewing  the  symptoms  of  inflammation  of  the  colon  in  its 
severe  forms,  we  have  been  struck  with  the  occasional  absence  of 
febrile  symptoms,  as  indicated  by  a  hot  skin,  furred  tongue,  or  excited 
pulse.  The  tongue,  unless  it  be  itself  affected  with  local  disease, 
indicates  the  condition  of  all  the  nutritive  functions,  rather  than 
that  of  any  isolated  portions  of  the  alimentary  canal.  The  tempera- 
ture in  dysentery  may  remain  about  the  normal  standard  or  it  may 
be  considerably  raised,  especially  in  those  instances  which  are  con- 
nected with  blood-poisoning. 

If  the  peritoneum  becomes  inflamed,  or  if  the  extension  of  disease 
to  the  muscular  coat  produces  irregular  muscular  contraction,  pain 
often  of  a  severe,  griping,  and  of  a  paroxysmal  character  is  the 
result.  The  amount  of  pain  appears  to  be  greater  in  disease  of  the 
small  than  of  the  large  intestine,  perhaps  on  account  of  its  greater 
mobility. 

The  character  of  the  evacuations  deserves  particular  attention. 
They  may  consist  of  fluid  feces  containing  scybala,  or  only  of  mucus 
with  blood.  The  mucus  is  often  tenacious,  and  passed  in  considerable 
quantity,  with  much  tenesmus,  forming  a  gelatinous  mass,  and  is 
occasionally  accompanied  with  small  scybalous  masses.  The  dis- 
charge becomes  in  severe  cases  thinner,  greenish  in  color,  and  even 
like  spinach;  or  from  the  admixture  of  more  blood  it  resembles  the 
"washings  of  meat."  The  inflamed  colon,  by  its  spasmodic  contrac- 
tion, prevents  the  discharge  of  the  more  healthy  contents,  which  are 
retained  above  the  seat  of  disease;  or  they  are  passed  very  rapidly, 
in  a  fluid  state,  whilst  the  pouches  of  the  colon  are  filled  with  con- 
solidated masses,  which  when  discharged  form  the  scybala  previously 
alluded  to. 

The  cessation  of  the  discharge  of  blood  and  of  mucus,  the  absence 
of  tenesmus,  and  the  presence  of  bilious  fecal  evacuation,  are  signs 
of  returning  health. 

The  violent  and  often  most  distressing  tenesmus  is  caused  by  the 
involuntary  action  of  the  muscular  fibres  of  the  rectum,  and  by  the 


306  ON    DYSENTERY    AND 

abnormal  sensibility  of  the  lower  bowel ;  for  where  the  latter  part 
is  not  affected  the  tenesmus  is  much  less  severe. 

The  sympathetic  connection  of  the  large  intestine  with  the  cerebro- 
spinal  system  and  with  other  organs,  although  of  an  intimate  kind,  is 
less  than  that  of  the  small  intestine  or  of  the  stomach ;  the  function 
of  these  parts  is  very  different  in  relation  to  the  vital  processes. 
The  large  intestine  is  an  elongated  receptacle  for  waste  material ;  it 
is  excretive  in  its  function,  although  closely  connected  with  the  con- 
dition of  the  blood,  and  affected  by  general  causes;  the  small  intes- 
tine, on  the  contrary,  whilst  in  part  excretive,  is  more  especially 
connected  with  the  absorption  of  nutritive  substances,  by  its  capil- 
laries and  its  villi,  and  with  the  subsequent  elaboration  of  chyle,  by 
means  of  the  mesenteric  and  other  glandular  structures.  Hence  we 
find  less  disturbance  of  the  pulse,  and  of  circulation  generally,  less 
acute  changes  in  the  cerebral  functions,  and  less  modification  of  the 
appetite,  &c.,  in  disease  of  the  large  than  of  the  small  intestine.  The 
urino-genital  organs,  however,  sometimes  sympathize  in  attacks  of 
dysentery,  and  we  find  the  patient  suffering  from  difficulty  in  mictu- 
rition. 

Cerebral  symptoms  have  been  described  by  many  observers  as 
being  present  in  the  worst  forms  of  dysentery,  as  stupor,  delirium, 
and  typhoid  symptoms  closely  resembling  fever;  but  these  symptoms 
were  not  present  in  the  cases  that  have  come  under  rny  notice,  unless 
associated  with  pneumonia;  but  it  must  not  be  forgotten  that  true 
enteric  or  other  fevers  may  be  combined  with  dysentery. 

Severe  symptoms,  indicative  of  great  functional  excitement  of  the 
nervous  system,  were  observed  in  the  Millbank  Penitentiary,  such 
as  cramps,  catalepsy,  tetanus,  &c.  The  peculiar  condition  of  the 
patients,  depressed  in  mind,  deprived  of  their  wonted  excitement, 
and  of  the  influence  of  their  usual  habits  and  associations,  a  spare 
diet,  &c.,  were  probably,  as  Dr.  Baly1  states,  the  causes  of  the  latter 
symptoms.  In  some  the  cramps  were  as  severe  as  in  Asiatic  cholera. 

Intermittent  and  remittent  fevers  are  sometimes  associated  with 
dysentery,  and  increase  the  severity  of  the  disease.  Dr.  MoreheaJ, 
however,  has  rarely  observed  them.2 

Causes. — Exposure  to  noxious  and  miasmatic  effluvia  appears  to 
be  the  most  fertile  source  of  the  disease,  especially  when  associated 
with  sudden  changes  in  the  temperature.  If  with  the  predisposing 
cause  of  offensive  effluvia  there  be  associated  exposure  to  cold  and 
wet,  especially  during  the  hours  of  night,  if  the  common  attendants 
of  poverty  be  present,  as  sleeping  in  damp  rooms,  clothing  inadequate 
to  counteract  the  inclemency  of  the  weather,  diet  improper  and 
scarcely  sufficient  to  sustain  life,  intemperance,  anxious  and  depress- 
ing cares,  we  have  ample  exciting  causes  of  dysentery;  and  many 
of  those  who  are  thus  attacked  are  also  enfeebled  by  other  disease, 
as  by  struma,  or  phthisis. 

The  effluvia  from  drains  and  from  decomposing  organic  substances 

1  Baly  on  '  Dysentery.'     '  Gulstonian  Lectures.' 

2  Morehead  on  '  Diseases  of  India.' 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  367 

are  common  causes  of  dysentery,  and  are  sufficient  alone  to  produce 
the  disease. 

Dysentery  often  prevails  after  scarcity  of  food,  and  terrible  mani- 
festations of  this  fact  have  occurred  in  Ireland.  The  observations 
there  made  by  some  of  its  most  accomplished  physicians,  and  the 
valuable  reports  they  have  furnished,  give  some  of  the  most  faithful 
descriptions  which  we  possess  of  dysentery  in  its  worst  forms.  I 
refer  to  the  labors  of  Drs.  Mayne,  Malcolm,  Lalor,  Harty,  Young,  &c. 

In  the  active  life  of  a  soldier,  especially  in  the  tropics  and  in 
marshy  districts,  these  causes  operate  in  all  their  intensity ;  and  the 
disease  thus  manifested  is  more  fatal  than  the  field  of  battle  itself. 
Such  has  been  the  testimony  of  nearly  all  the  writers  on  military 
surgery  and  medicine. 

Inflammation  of  the  colon  is,  however,  set  up  without  any  mias- 
matic influence  ;  thus,  from  poisons,  inflammation  of  the  stomach 
and  the  colon  may  be  produced  without  the  intervening  small  intes- 
tine being  affected  ;  so  also  from  irritating  ingesta  and  excretions 
which  appear  in  some  instances  to  be  the  sole  cause  of  the  complaint. 
Cold  drinks  in  excess  during  summer  heat  also  tend  to  produce  dys- 
entery. 

Many  believe  in  the  contagious  character  of  the  disease.  Thev 
have  found  it  to  extend  from  one  patient  to  another,  to  attendants, 
or  from  house  to  house,  &c. ;  but  it  must  be  remembered,  1st,  that 
in  many  of  these  cases  there  is  a  general  pervading  atmospheric  in- 
fluence, miasmatic  or  otherwise  ;  2d,  that  the  effluvia  from  the  dys- 
enteric discharges  are  exceedingly  offensive;  3d,  that  animal  effluvia 
are  of  themselves  sufficient  to  induce  the  complaint ;  4th,  that  the 
effect  of  night- watching,  and  of  witnessing  the  rapidly  fatal  termina- 
tion of  the  disease,  is  to  depress  the  healthy  tone,  and  weaken  the 
power  of  resisting  the  complaint. 

The  occasional  similarity  of  dysentery  to  enteric  fever,  or  the 
occurrence  of  the  two  diseases  at  the  same  time  and  in  the  same 
patient,  do  not  warrant  us  in  considering  the  one  as  of  the  same 
character  or  type  of  disease  as  the  other,  namely,  a  blood  disease 
associated  with  special  changes  in  the  glands  of  the  intestine.  There 
are  few  diseases  that  have  not  more  or  less  of  a  constitutional  origin, 
and  dysentery  is  doubtless  of  that  character  ;  but  while  in  some  there 
is  evidence  of  a  poison  contaminating  the  blood,  and  leading  to  a 
special  train  of  symptoms,  as  in  smallpox,  or  in  pyaemia,  there  does 
not  appear  to  be  any  warrant  for  supposing  that  such  is  the  case  in 
dysentery,  more  than  in  ulcerative  stomatitis.  Some  cases  of  dys- 
enterjr,  as  of  pneumonia,  doubtless  arise  from  a  diseased  condition  of 
blood,  whilst  others  are  of  a  local  character ;  thus,  pneumonia  may 
be  produced  by  direct  exposure  to  cold ;  or,  the  blood  may  be  in 
such  a  condition  from  pyaemia  and  other  septic  changes,  that  it  is 
induced  without  any  other  exciting  cause;  in  like  manner  some  of 
the  cases  of  dysentery  here  recorded  appeared  to  be  produced  by 
irritation  extending  from  the  rectum ;  others  from  direct  irritation 
caused  by  improper  food ;  while  a  third  class  arises  from  a  morbid 
condition  of  the  whole  circulating  fluid. 


368  ON    DYSENTERY    AND 

As  far  as  our  observations  extend,  we  are  disposed  to  agree  with 
the  statements  of  Dr.  Harty,  in  the  'Dublin  Quarterly  Review' — 1st, 
that  genuine  and  simple  dysentery  is  unattended  with  idiopathic 
f jver,  and  is  never  of  itself  contagious ;  2d,  that  every  form  of  the 
disease  when  epidemic  is  a  combination  of  simple  dysentery  either 
with  intermittent,  remittent,  or  continued  fever;  and  3d,  that  the 
form  of  dysentery  which  is  combined  with  fever  is  alone  contagious. 

The  Prognosis  of  dysentery  is  unfavorable  when  purging  of  blood, 
and  thin  serous  offensive  discharge  like  the  washings  of  meat  con- 
tinue ;  when  there  is  involuntary  discharge  from  the  bowels,  with 
great  tenderness  of  the  abdomen,  vomiting,  red  and  glazed  tongue, 
typhoid  symptoms,  irregular  pulse,  refusal  of  food,  restlessness,  and 
great  prostration  of  strength,  or  when  these  symptoms  have  con- 
tinued for  a  considerable  time,  and  one  relapse  has  followed  an- 
other, without  the  patient  in  the  interval  regaining  strength,  but 
retaining  the  same  sallow  and  haggard  expression ;  when,  also, 
there  are  cerebral  symptoms,  as  coma,  delirium,  or  convulsions,  we 
judge  unfavorably.  On  the  contrary,  when,  on  the  removal  of  the 
causes  of  the  disease,  the  evacuations  assume  a  healthy  appearance, 
and  contain  bile,  when  the  pulse  remains  firm,  and  the  prostration 
becomes  less,  when  the  tenesmus  ceases,  and  the  patient  gains 
strength,  we  may  give  a  cheering  prognosis. 

Diagnosis. — There  are  several  conditions  which  may,  unless  due 
care  be  used,  be  mistaken  for  dysentery. 

1.  The  discharge  of  blood  from   hemorrhoids,  accompanied    with 
diarrhoea  and   prostration.      Ordinary   care   alone   is   necessary  to 
guard  against  this  error. 

2.  Disease  of  the  rectum.^-The  lower  part  of  the  rectum  sometimes 
becomes  ulcerated,  and  leads  to  a  discharge  of  mucus  and  blood  with 
tenesrnus,  and  with  great  anxiety  and  sympathetic  nervous  distur- 
bance to  the  patient.     It  will  be  found  in  many  of  these  cases,  that 
a  small  quantity  of  mucus  or  pus  escapes  from  the  rectum  at  irregu- 
lar intervals.     In  organic  constriction  of  the  rectum,  whether  can- 
cerous or  otherwise,  the  bowels  are  sometimes  in  a  loose  condition. 

8.  Polypus  in  the  rectum  will  produce  like  symptoms.  Many  of 
these  growths  can.  be  detected  by  examination  per  rectum  ;  others, 
however,  are  beyond  the  reach  of  the  finger,  and  we  can  then  only 
decide  by  the  clinical  history  of  the  case.  In  these  instances  healthy 
feces  are  passed,  but  coated  or  followed  by  mucus  or  pus,  and  the 
constitutional  disturbance  is  less  severe. 

4.  Fibro-celhdar  ulceration. — By  this  we  mean  a  condition  of  rectum 
which  is  not  cancerous,  but  in  which  the  mucous  membrane  is  ulce- 
rated and  the  coats  of  the  intestine  are  converted  into  dense  fibrous 
tissue,  and  often  syphilitic  in  its  origin. 

5.  Some  of  the  forms  of  diarrhoea  resemble  the  earlier  symptoms 
of  dysentery,  but  they  are  generally  distinguished  by  the  absence  of 
blood  with  mucus.     In  some  cases,  however,  where  there  is  disease 
of  the  mesenteric  glands,  with  persistent  diarrhoea,  and  prostration 
of  strength,  we  are  apt  to  believe  that  ulceration  of  the  colon  exists ; 
the  stools,  however,  are  different;  there  is  less  of  mucus,  and  no  blood 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  369 

can  be  detected  in  the  evacuation  even  by  microscopical  examina- 
tion. 

6.  A  feeble  condition  of  the  sphincter  ani,  and  of  the  muscular  coat 
of  the  intestine,  leading  to  the  involuntary  discharge  of  fluid  feces, 
might  induce  a  belief  in  an  abnormal  condition  of  the  mucous  mem- 
brane of  the  colon. 

7.  A  mass  of  hard  feces  in  the  rectum  which  the  patient  is  unable 
to  expel  produces  incessant  straining,  and  is  accompanied  with  the 
almost  constant  discharge  of  mucus  or  fluid  feces.     This  painful  con- 
dition is  often  mistaken  for  dysentery. 

Treatment. — Amongst  the  most  important  points  for  consideration 
in  the  treatment  of  dysentery  are  the  removal  of  all  exciting  causes, 
and  of  the  general  conditions  in  which  the  disease  has  had  its  origin. 
The  patient  should  be  clothed  in  flannel,  and  the  temperature  of  the 
body  maintained,  dampness  and  cold  carefully  warded  off,  improper 
diet  avoided,  and,  if  possible,  good  and  pure  air  inhaled. 

Demulcents  administered  by  the  mouth  have  a  long  distance  to 
traverse  before  reaching  the  large  intestine,  but  they  nevertheless 
act  very  beneficially  by  rendering  the  excreta  poured  into  the  colon 
less  irritating,  and  by  thus  soothing  the  diseased  membrane.  In  this 
way,  arrowroot,  linseed  tea,  mutton  and  veal  broth,  milk  with  suet, 
rice  milk,  tapioca,  &c.,  may  be  both  grateful  to  the  patient,  and  act 
remedially,  but  fluid  drinks  should  not  be  taken  in  great  excess; 
water  alone  has  been  used,  although  it  is  inferior  to  demulcent  drinks. 
By  these  simple  means  many  attacks  may  be  relieved,  and  the  pa- 
tients speedily  recover. 

The  diet  calls  for  much  attention,  equally  in  the  early  stages  and 
milder  forms,  as  at  a  later  period  or  in  cases  of  a  more  severe  char- 
acter; but  in  the  former  it  is  often  more  difficult  to  persuade  the 
patient  to  follow  our  directions;  being  free  from  pain,  the  tongue 
clean,  the  appetite  craving,  he  does  not  at  once  see  the  importance  of 
using  proper  care.  Any  imprudence  perpetuates  and  aggravates  the 
disease.  Malt  liquors  and  spirits  should  be  abstained  from.  Meat 
in  a  solid  form  is  generally  better  avoided  in  the  acute  disease,  but 
when  taken  it  should  be  in  an  easily  assimilable  form,  and  neither 
richly  dressed  nor  highly  seasoned. 

In  protracted  cases  of  dysentery,  it  is  necessary  to  take  animal 
food,  and  it  is  very  desirable  in  other  ways  to  sustain  the  strength  of 
the  patient  as  far  as  possible.  For  a  short  time,  at  least,  it  is  well  to 
omit  vegetables  and  fruit,  especially  when  uncooked;  but  oranges, 
grapes,  &c.,  by  supplying  to  the  system  that  which  is  necessary  for 
the  maintenance  of  sound  action,  without  much  indigestible  product, 
may  sometimes  be  taken  with  great  benefit  in  chronic  dysentery, 
although  apples,  and  stone  fruit,  melons,. salads,  &c.,  do  harm. 

Eest  is  important,  and  in  very  many  cases  the  patient  is  too  ill  to 
leave  the  recumbent  posture;  in  the  chronic  disease  also,  fatiguing 
muscular  exertion  and  horse  exercise  must  be  avoided.  It  is  useless 
to  attempt  to  treat  a  case  of  dysentery  if  the  patient  be  allowed  to 
walk  about,  or  to  assume  the  erect  position,  for  he  ought  to  be  per- 
fectly quiet  and  in  bed. 
24 


370  ON    DYSENTERY    AND 

Other  remedies  in  most  frequent  use,  have  been  opium,  astringents, 
both  metallic  and  vegetable,  ipecacuanha,  mercurials,  depletion,  ene- 
mata  of  various  kinds,  &c. 

Opium  is  of  almost  universal  application,  but  it  cannot  be  given 
indiscriminately,  either  alone  or  in  combination;  it  acts  partly  by  its 
astringent  properties,  and  partly  as  a  narcotic,  by  its  secondary  influ- 
ence upon  the  inflamed  mucous  membrane,  through  the  sympathetic 
system  of  nerves.  It  is  often  administered  alone,  but  more  frequently 
m  combination  with  ipecacuanha,  as  in  Dover's  powder;  or  with  as- 
tringents, as  in  the  compound  infusion  of  krameria,  or  compound 
logwood  mixture  of  Guy's;  or  in  combination  with  mercurials,  as 
calomel  and  gray  powder;  and  lastly,  in  enemata.  When  the  excreta 
are  depraved,  and  cause  irritation  of  the  intestine  by  their  presence, 
no  beneficial  result  is  attained  by  seeking  to  check  their  removal  by 
astringents. 

Mercurials. — Calomel  has  been  very  largely  and  notoriously  ad- 
ministered in  dysentery.  In  India  3j  doses  are  described  by  Annesley 
as  productive  of  essential  benefit ;  others  have  now  given  up  its  use 
altogether,  in  the  severe  dysenteries  of  the  East.  Its  administration, 
in  more  moderate  doses,  is  often  advantageous.  In  the  earliest  stages, 
where  the  motions  are  of  an  unhealthy  character,  pale,  or  containing 
hard  and  scybalous  masses,  it  may  be  well  to  give  a  dose  of  calomel, 
or  of  gray  powder,  followed  by  castor  oil,  guarded  by  opium  ;  or  the 
opium  may  be  combined  with  the  mercurial,  as  calomel  with  opium, 
or  gray  powder  with  Dover's  powder;  in  this  way  offending  sub- 
stances may  be  removed,  and  acrid  excretions  rectified  and  corrected ; 
but  it  is,  we  believe,  unwise  and  uncalled  for,  to  persist  in  the  use  of 
mercurials.  We  have  no  facts  to  show  that  the  inflammation  of  the 
mucous  membrane  is  diminished  by  its  action,  but  rather  that  it  is 
increased,  and  ulceration  accelerated,  although  the  abdominal  glands 
may  be  stimulated  to  a  more  healthy  action. 

Purgatives. — Almost  the  same  may  be  said  of  these  remedies,  as 
of  mercury.  In  the  earlier  stages  of  dysentery  and  dysenteric  diar- 
rhoea, when  oftentimes  irritating  and  crude  materials  are  retained, 
and  equally  irritating  secretions  are  poured  out,  purgatives  are  of 
great  value;  castor  oil  and  linseed  oil,  with  tincture  of  rhubarb,  and 
with  small  doses  of  tincture  of  opium,  are  old  and  valuable  remedies 
for  this  purpose.  They  may  be  repeated  several  times  during  the 
day,  with  manifest  improvement  of  the  alvine  evacuations,  and  relief 
to  the  tenesrnus  and  the  pain.  This  administration  of  a  laxative 
draught,  followed  by  a  full  dose  of  Dover's  powder,  or  chalk  with 
opium  is  the  best  treatment  for  ordinary  dysentery  at  its  onset. 
Violent  purgatives  are,  however,  neither  beneficial  nor  warrantable. 
Ipecacuanha  was  introduced  into  Europe  as  a  remedy  for  dysentery, 
nearly  170  years  ago,  and  has  been  used  with  success  since  that  time; 
large  doses  have  been  given  without  producing  vomiting,  as  by  Sir 
J.  Pringle,  in  gr.  v,  to  9j,  and  by  Mr.  Twining,  with  extract  of  gentian; 
but  much  smaller  doses  are  equally  effective.  Ipecacuanha  appears 
to  have  the  same  beneficial  action  in  inflammation  of  the  alimentary 
as  of  the  respiratory  mucous  membrane,  in  relieving  the  congestion, 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  371 

and  in  restoring  healthy  secretion.  It  is  one  of  the  most  valuable 
remedies  in  acute  dysentery,  and  much  larger  doses  can  be  tolerated 
by  the  stomach  if  given  soon  after  nourishment.  It  has  been  given 
in  various  combinations,  frequently  with  opium,  and  with  vegetable 
astringents,  as  kino,  krameria,  logwood,  catechu,  &c. 

Astringents  are  of  greater  value  in  chronic  than  in  acute  dysen- 
tery ;  sulphate  of  copper,  acetate  of  lead,  oxide  and  nitrate  of  silver, 
nitrate  of  bismuth,  sulphate  and  pernitrate  of  iron,  have  all  been  used; 
several  of  these  act  by  their  direct  astringent  property,  others  be- 
come absorbed  and  are  sedatives  to  the  mucous  membrane ;  some  of 
these  remedies  have  been  used  in  combination  with  opium,  as  copper 
and  lead;  others  with  considerable  success  as  injections,  and  in  that 
way  applied  directly  to  the  diseased  surface;  thus  nitrate  of  silver 
has  been  used  as  an  enema  by  Trousseau,  in  the  proportion  of  gr.  x 
to  xv  to  a  pint  of  distilled  water ;  so  also  borax  in  about  9j  doses ; 
in  some  cases  I  have  used  charcoal,  3ij,  with  Oss  of  thin  gruel,  with 
evident  relief. 

Vegetable  astringents  are  valuable  remedies  in  the  chronic  disease, 
and  even  in  the  acute  stage  after  the  removal  of  irritating  excreta 
and  scybala,  as  krameria,  kino,  logwood,  and  catechu,  tormentilla, 
and  sirnaruba;  they  are  of  especial  service  when  given  in  combina- 
tion, as  ipecacuanha  with  catechu  and  krameria  (Infusum  Krameriae 
Compositum.  Ph.  Guy's).  Cusparia  is  a  more  stimulating  astringent 
and  tonic,  and  is  often  of  great  benefit  after  the  more  active  symp- 
toms have  subsided.  Tannin  and  gallic  acid  have  been  used,  and 
may  be  given  advantageously  in  doses  of  "ixx-xxx  of  the  solution 
in  glycerine,  with  tt^x-xx  of  spirit  of  chloroform  and  water.  The 
rind  of  the  pomegranate  root  is  a  favorite  remedy  with  some,  but  it 
is  a  less  effective  astringent  than  others  just  mentioned.  I  have  tried 
the  Indian  Bael  in  many  instances  of  chronic  dysentery,  but  I  have 
not  seen  it  followed  by  the  benefits  which  were  anticipated  from  the 
high  encomiums  given  to  it  by  practitioners  in  India.  The  solution 
of  potash,  as  well  as  the  bicarbonate  of  potash,  and  the  correspond- 
ing preparations  of  soda,  diminish  intestinal  irritation  in  the  acute 
disease ;  they  are  best  given,  however,  in  combination  with  opium, 
or  henbane  and  astringents. 

Earthy  astringents. — Chalk,  alone  or  combined  with  opium  and 
astringents,  is  one  of  the  ordinary  remedies  at  the  outset  of  dysen- 
teric diarrhoea,  and  is  frequently  sufficient  to  check  the  purging; 
but  in  many  cases  no  form  of  astringent  or  sedative  will  serve  to 
restrain  this  symptom,  whilst  irritating  excreta  and  other  substances 
are  retained;  and  in  others,  so  great  is  the  extent  of  the  disease, 
that  it  is  futile  to  attempt  to  check  it  by  a  grain  or  two  of  medicine 
which  acts  locally,  whilst  the  disease  extends  over  many  feet  of 
intestine.  By  demulcents,  by  removing  the  cause  of  the  disease,  by 
rest,  by  correcting  the  general  disturbance,  and  by  sustaining  the 
patient  during  the  degenerative  changes  which  are  in  operation,  we 
must  seek  to  shorten  the  morbid  process  and  to  restore  health. 

Mineral  acids.— After  the  urgency  of  the  symptoms  have  subsided, 
mineral  acids,  both  sulphuric  and  nitric,  appear  to  act  beneficially 


372  ON    DYSENTERY    AND 

on  the  mucous  membrane  in  restoring  healthy  vigor.  I  have  not 
found  the  benefit  from  dilute  sulphuric  acid  that  some  practitioners 
have  observed;  still  it  is  a  remedy  of  value,  and  well  deserves  a 
trial;  and  in  chronic  dysentery  the  nitric  and  nitre-hydrochloric 
acids  are  often  of  service  when  combined  with  opiurn,  and  with  the 
milder  vegetable  astringents.  Quinine. — The  combination  of  quinine 
with  Dover's  powder,  or  with  mineral  acids  and  astringents,  is  pro- 
ductive of  considerable  relief  in  those  cases  of  chronic  dysentery 
which  have  been  perpetuated  and  aggravated  by  residence  in  mias- 
matic districts. 

Warm  enemata  often  afford  very  great  relief  by  washing  out  the 
lower  part  of  the  rectum,  and  by  soothing  the  inflamed  membrane; 
in  this  way  gruel,  thin  starch,  and  barley  water  may  be  used  with 
much  relief;  but  their  efficiency  is  increased  by  the  addition  of 
tincture  of  opium.  Borax  and  nitrate  of  silver  are  used,  as  we  have 
before  mentioned,  and  sometimes  charcoal;  these  agents  and  vege- 
table astringents,  as  oak  bark,  have  been  more  especially  tried  in 
chronic  dysentery. 

Suppositories,  composed  of  opiates  or  anodynes,  or  bismuth,  afford 
much  relief  to  the  tenesmus,  but  are  less  effective  than  enemata.  In 
the  constipation  which  follows  the  cicatrization  of  dysenteric  ulcers, 
much  relief  is  afforded  by  the  use  of  sedatives  with  aperient  medi- 
cine, as  by  the  colocynth  and  henbane  with  ipecacuanha,  and  by 
belladonna  with  rhubarb  and  capsicum. 

A  change  to  more  genial  climate  is  often  productive  of  the  most 
beneficial  result;  this  applies  especially  to  residents  in  India,  and 
to  those  who  have  contracted  dysentery  in  our  own  country  in  damp 
and  miasmatic  districts. 

The  following  39  fatal  cases  of  dysentery  were,  with  one. or  two 
exceptions,  produced  in  our  own  country,  and  will  illustrate  the 
causes  of  death  in  this  disease;  they  indicate, 

I.  That  dysentery  of  a  most  severe  form  arises  in  our  own  country, 
and  is  not  of  unfrequent  occurrence. 

II.  That  the  cause  of  death  in  some  is  the  extent  and  severity  of 
the  affection. 

III.  That  others  die  from  perforation  and  fecal  abscess. 

IV.  That  suppuration  in  some  of  the  branches  of  the  portal  vein 
and  hepatic  abscess   follow  some  of  the  worst  forms  of  English 
dysentery. 

V.  That  the  constriction  of  the  intestine  sometimes  leads  to  abscess 
in  the  parietes  and  to  artificial  anus. 

VI.  That  in  the  worst  cases  astringents  and  opiates  are  ineffective. 

VII.  That  injections  and  demulcent  remedies  afford  considerable 
relief,  and  in  mild  cases  will  alone  be  sufficient ;  but  are  inferior  in 
their  efficacy  to  astringents  and  opium. 

VIII.  That  rest  even  in  mild  cases  is  desirable. 

Many  cases  have  presented  themselves,  in  my  own  practice  and 
spheres  of  observation,  where  these  means  checked  the  purging,  and 
restored  health. 

IX.  That  as  far  as  can  be  judged,  mercurial  preparations,  if  con- 
tinued, would  have  been  injurious. 


CATARRHAL    INFLAMMATION    OP    THE    COLON. 


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CATARRHAL    INFLAMMATION    OF    THE    COLON.  375 

CASE  CXXVII.    Inflammation  of  Colon.     Diphtheria  of  the  Pharynx 

Harriet  S— ,  aet.  28,  was  admitted  July  18t'-,  1855,  under  my  care. 

She  was  a  pale,  thin  woman,  who  had  resided  in  the  Borough,  the  wife  of 
a  butcher,  and  she  had  been  out  of  health  for  six  months,  with  occasional 
diarrhoea ;  but  during  seven  weeks  she  had  become  much  worse.  Her  illness 
came  on  after  exposure  to  cold  on  entering  a  new  house;  she  had  great  lassi- 
tude, weariness,  and  severe  pain  in  the  limbs.  These  symptoms  "increased, 
and  she  was  admitted  into  St.  Thomas's  Hospital,  and  whilst  there  she  passed 
blood  and  mucus  from  the  bowels.  She  stated  that  her  family  were  healthy, 
but  that  she  had  previously  had  an  attack  of  inflammation  of  the  bowels.  On 
admission  she  had  the  appearance  of  a  patient  suffering  from  acute  pneumonic 
phthisis;  the  lips  and  nostrils  were  thin;  the  cheeks  were  sunken;  the  skin 
was  hot  and  clammy;  the  conjunctiva  and  skin  generally  were  of  a  very 
slight  jaundiced  color.  Along  the  gums  was  a  pale  red  line;  the  tongue  was 
coated  with  a  yellow  fur,  dry  and  brown,' and  at  its  centre  there  were  several 
aphtlious  patches;  the  throat  was  dry  and  injected;  she  complained  of  diffi- 
culty in  swallowing,  and  it  was  painful  to  her  to  speak  much.  The  pulse 
was  112,  soft  and  full.  In  the  abdomen  a  large  mass  of  the  form  of  the  liver 
could  be  felt,  extending  nearly  to  the  crest  of  the  ileum,  and  across  the 
umbilical  region.  The  abdomen  was  flaccid,  but  slightly  tender  on  manipu- 
lating the  right  hypochondriac  region.  The  motions  were  passed  involun- 
tarily, and  were  slimy  and  of  a  green  color;  three  or  four  were  passed  in  an 
hour.  She  was  treated  with  astringents  and  opium,  but  gradually  became 
more  prostrate,  and  died  on  the  23d. 

On  inspection,  the  pharynx,  the  posterior  part  of  the  tongue,  the  tonsils, 
and  the  anterior  part  of  the  epiglottis  were  covered  with  a  yellowish-white 
crust ;  this  was  very  adherent  to  the  lateral  portions  of  the  root  of  the  tongue  ; 
and  on  the  glossal  surface  of  the  epiglottis  this  membrane  was  so  fixed  that 
it  could  not  be  washed  off  by  water.  The  surface  of  the  epiglottis  beneath 
it  was  much  injected,  but  only  towards  the  tongue.  On  examining  a  portion 
of  this  substance  it  was  found  to  consist  of  delicate  interlacing  torulae,  some 
jointed,  and  much  resembling  the  torula  cerevisia?;  it  was  mixed  with  par- 
ticles of  fat.  The  larynx,  internal  surface  of  the  epiglottis,  trachea,  and 
bronchi  were  all  free  from  disease.  The  lungs  were  healthy,  so  also  the 
pleura.  The  muguet  did  not  extend  to  the  resophagus,  excepting  at  its  upper 
part.  The  heart  and  pericardium  were  healthy. 

Abdomen — There  were  old  adhesions  of  the  omentum.  The  stomach  was 
healthy,  and  on  microscopical  inspection  its  follicles  were  full  of  secreting 
cells  and  granules,  with  a  small  quantity  of  highly  refracting  particles.  The 
liver  extended  to  the  right  iliac  region;  it  was  exceedingly  fatty,  of  pale 
yellow  color,  and  lighter  than  water.  The  gall-bladder  was  contracted  and 
empty;  the  weight  of  the  liver  8  Ib.  6  oz.  Spleen,  corpuscles  distinct,  its 
weight  C>^  oz. 

The  peritoneum  was  healthy;  there  was  a  moderate  amount  of  fat  in  the 
mesentery,  and  the  glands  near  the  caecum  were  enlarged  and  somewhat 
swollen.  The  intestines  were  moderately  distended.  On  opening  the  colon 
it  was  found  to  contain  fluid  feces;  the  whole  mucous  membrane  was  covered 
by  an  adherent  whitish  layer,  having  a  granular,  almost  villous  appearance; 
it  was  of  a  )ellowish-red  color,  which  was  more  marked  towards  the  rectum; 
the  mucous  membrane  was  swollen,  and  in  some  parts  presented  small  aphtlious 
ulcers  about  a  quarter  of  an  inch  in  diameter.  The  submucous  cellular  tis- 
sue was  white  and  thickened;  the  muscular  coat  also  appeared  very  thick 
and  distinct.  The  false  membrane  consisted  of  a  blastema  containing  gran- 
ules, highly  refracting  particles,  and  some  cells,  but  no  well-marked  cells  nor 


376  ON    DYSENTERY    AND 

epithelium.  The  last  foot  of  the  ileum  was  much  injected,  and  presented 
M-vcral  irregular  ulcers,  but  no  membrane  similar  to  that  in  the  ca-cum  and 
colon. 

The  kidneys  were  pale  and  large,  their  weight  11  oz.  The  uriniferous 
tubes  contained  granules  and  oil  particles. 

This  case  of  acute  inflammation  of  the  colon  carne  on  gradually. 
For  six  months  the  patient  had  attacks  of  diarrhoea,  but  for  seven 
weeks  the  symptoms  were  severe,  and  of  the  character  of  dysentery ; 
the  motions  contained  blood  and  mucus,  and  became  afterwards  green 
and  slimy.  On  admission  into  Guy's  Hospital  she  was  in  a  typhoid 
condition,  and  almost  dying.  Her  general  appearance  resembled  a 
case  of  pneumonic  phthisis  with  dysentery,  but  there  was  no  physi- 
cal signs  of  phthisis.  The  astrjngents  which  were  administered  af- 
forded only  very  temporary  relief,  and  opium  quickly  produced  torpor 
the  brain. 

CASE  CXXVIII.  Diphtherite  of  the  Colon.  Dysentery.  Chorea —  ' 
Elizabeth  H — ,  aet.  7  years,  was  admitted  into  Guy's,  February,  18^5.  She 
was  a  dark,  strumous  child,  who  five  weeks  previously,  without  apparent 
cause,  became  affected  with  chorea;  she  improved  under  the  use  of  sulphate 
of  zinc  gradually  increased,  and  purgatives  had  been  required,  for  the  bowels 
were  generally  constipated.  A  few  days  before  death  diarrhoea  came  on  with 
prostration,  and  with  symptoms  very  much  resembling  Asiatic  cholera;  the 
motions  consisted  at  first  of  blood  and  mucus,  but  afterwards  of  thin  and 
watery  fluid.  On  the  seventh  day  after  the  onset  of  the  purging  the  child 
died. 

Inspection — The  eyes  were  much  sunken.  The  cerebral  veins  were  full 
of  partially  decolorized  clot,  and  the  ventricles  of  the  brain  contained  more 
than  the  normal  quantity  of  fluid.  The  lungs  appeared  healthy,  except  a 
circumscribed  patch  at  the  middle  of  the\  left  lung,  where  was  a  strumous 
mass  about  the  size  of  a  hazel-nut,  and  some  tubercles  around  it.  The  inner 
aspect  of  the  mitral  valve  was  fringed  with  minute  vegetations,  firm,  semi- 
transparent,  and  surrounding  the  edge  of  the  valve;  the  largest  of  them  was 
of  the  size  of  a  pin's  head.  The  inner  surface  of  the  tricuspid  was  slightly 
roughened.  The  pericardium  was  healthy.  The  weight  of  the  heart  was 
3£  oz. 

The  stomach  was  healthy.  In  the  jejunum  a  few  of  Peyer's  patches  were 
visible  and  were  injected ;  in  the  ileum  they  were  very  distinct,  and  near 
the  caecum  were  covered  with  a  delicate  inflammatory  deposit  of  lymph. 
The  large  intestine  was  diseased  throughout.  The  whole  of  the  mucous 
membrane  was  of  a  dark-green  color,  covered  with  a  firm  granular  deposit  of 
lymph.  The  disease  increased  in  severity  from  the  caecum  downwards.  The 
crecum  was  acutely  inflamed,  being  of  a  red  color,  and  the  mucous  membrane 
was  entire.  Lower  down  the  mucous  membrane  became  green,  and  was 
covered  with  inflammatory  deposit ;  and  in  the  rectum  the  inner  surface  was 
raised  into  folds  or  irregularly  shaped  eminences.  In  the  descending  colon, 
when  the  adventitious  product  was  removed,  the  tissue  was  seen  to  be  swollen, 
full  of  blood,  and  in  some  parts  superficially  ulcerated.  The  muscular  coat 
was  much  thickened.  The  kidneys  were  healthy. 

This  case  was  supposed  to  be  one  of  Asiatic  cholera,  and,  unless  a 
careful  inspection  had  been  made,  it  might  have  been  so  recorded. 
The  suddenness  of  the  diarrhoea,  the  rapid  collapse  and  prostration, 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  377 

closely  resembled  that  disease.  Other  cases  of  cholera  had  occurred 
about  the  time.  The  treatment  used — starch  and  opium  injections, 
&c.,  did  not  appear  to  have  any  effect  upon  the  malady. 

CASE  CXXIX.  Inflammation  of  the  Colon.    Hernia Ann  H — ,  aet.  60, 

was  a  single  woman,  a  servant,  who  had  resided  at  Peckham,  and  she  was 
admitted  into  Guy's  Hospital  February  6th,  1857.  For  ten  years  she  had 
had  hernia,  but  her  general  health  was  good.  Five  days  before  admission 
the  hernia  came  down,  she  was  seen  by  a  practitioner,  and  after  taking  croton 
oil,  various  purgatives,  shot,  &c.,  was  admitted  into  Guy's.  She  was  much 
depressed  and  collapsed;  the  symptoms  were  constipation,  stercoraceous  vomit- 
ing, great  pain  in  the  abdomen,  and  some  tenderness.  A  tolerably  large 
femoral  hernia  was  found  in  the  right  inguinal  region.  A  grain  of  opium 
was  given  at  once,  and  the  hernia  was  reduced  by  taxis  without  difficulty. 
On  the  following  day,  the  7th,  the  bowels  were  opened,  and  the  patient  felt 
better.  A  grain  of  calomel  and  one  of  opium  were  administered,  and  repeated 
every  four  hours ;  and  she  was  allowed  beef  tea.  The  diarrhoea  continued 
notwithstanding  the  use  of  various  remedies,  and  she  died  from  exhaustion 
on  the  nineteenth  day  after  the  commencement  of  the  illness.  For  some  time 
before  death  there  was  low  muttering  delirium,  cold  extremities,  and  an 
almost  imperceptible  pulse. 

Inspection  was  made  a  few  hours  after  death.  The  body  was  much  wasted, 
and  the  eyes  were  sunken.  The  lungs  and  pleura  were  quite  healthy,  and 
the  lungs  were  collapsed  ;  the  heart  was  small. 

Abdomen The  peritoneum  was  healthy ;  the  oesophagus  was  normal,  so 

also  was  the  stomach  ;  the  jejunum  was  congested,  the  valvulae  conniventes 
were  covered  with  mucus.  Eight  feet  from  the  caecum  a  portion  of  the  ileum 
about  four  inches  long  was  of  a  deep  purple  color,  and  had  evidently  been 
strangulated ;  it  appeared  to  be  recovering.  Below  the  strangulation  the 
ileum  became  much  more  congested,  and  for  four  feet  from  the  cjecum  the 
intestine  was  acutely  inflamed ;  the  mucous  membrane  was  covered  by  a 
yellowish-green  adherent  exudation,  nearly  a  line  in  thickness,  which  was 
with  difficulty  removed.  The  valvulae  conniventes  were  exceedingly  promi- 
nent, rigid,  and  erect.  The  whole  of  the  mucous  membrane  was  much  thick- 
ened, the  muscular  coat  more  than  a  line  in  thickness,  and  the  areolar  tissue 
very  osdematous. 


Section  of  the  mucous  membrane  of  a  portion  of  the  ileum  in  acute  inflammation  of  the  colon  and 
ileum,  showing  the  surface  covered  with  false  membrane   (diphtherite)  and  continuous  with 
mucous  follicles. 

On  making  a  section  of  this  portion  of  intestine,  the  exudation  was  found 
to  consist  of  cells  and  granules,  and  appeared  to  be  quite  continuous  with  the 
follicles  of  the  mucous  membrane  (LeiberkUhn's  ;  these  follicles  were 


378  ON    DYSENTERY    AND 

ingly  distinct,  and  were  evidently  distended  to  the  utmost.  It  appeared  that 
the  secretion  from  these  follicles  was  changed  by  the  diseased  action,  that  it 
was  excessive  in  quantity,  and  abnormal  in  quality ;  the  form  of  the  follicles 
was  retained  by  the  exudation  on  the  surface,  as  if  it  had  been  exuded 
rapidly.  The  submucous  cellular  tissue  was  much  thickened  from  inflam- 
matory oedema. 

The  colon  from  the  caecum  to  the  rectum  was  still  more  diseased  ;  in  the 
caecum  the  mucous  membrane  had  a  reddish-gray  color,  with  minute  highly 
injected  points  studding  the  surface  ;  some  of  these  points  presented  a  darker 
colored  centre,  others  were  scarlet.  In  the  place  of  others  were  minute 
ulcers ;  the  mucous  membrane  being  eroded ;  the  edges  of  the  ulcers  were 
injected ;  their  surface  whitish-gray,  but  there  was  no  apparent  slough. 
In  the  ascending  colon  more  of  the  mucous  membrane  was  destroyed,  and 
elongated  ulcers  were  found,  about  half  an  inch  in  length,  with  irregular,  in- 
jected or  partially  undermined  margins,  their  base  consisting  of  whitish 
lymph-like  exudation ;  between  these  ulcers  there  were  minute  red  points  or 
red  mucous  membrane  covered  with  exudation.  The  whole  of  the  colon 
presented  a  similar  appearance,  even  to  the  rectum.  The  appendix  casci  was 
long,  and  at  its  extremity  were  about  a  half  a  dozen  small  shot. 

The  examination  of  the  mucous  membrane  of  the  cajcum  showed  that  the 
minute  red  points  were  solitary  glands.  (The  cut  represents  one  of  these  red 


Section  of  a  solitary  gland  from  tlie  caecum,  from  the  same,  showing  (a)  the  edges  of  a  raised 
portion  intensely  injected  from  distended  capillaries  ;  (6)  surface  of  mucous  membrane  covered  with 
diphtheritic  granular  membrane;  (c)  opening  into  the  gland  ;  (d)  small  phosphatic  crystals. 

glands,  having  a  deeply  colored  centre).  The  portion  above  the  level  of  the 
mucous  membrane  showed  distended  capillaries,  and  there  was  in  the  centre 
an  opening  extending  into  the  gland.  In  the  gland  were  minute  nuclei,  and 
a  large  nucleated  cell  was  observed.  It  appeared  probable,  from  the  darker 
color  of  the  congested  part,  that  the  circulation  in  these  capillaries  had  nearly 
ceased,  and  that  in  a  short  time  sloughing  would  have  taken  place.  The 
adjoining  mucous  membrane  presented  an  appearance  somewhat  similar  to 
that  found  in  the  ileum,  but  the  follicles  were  less  distinct.  Some  crystals 
were  observed  on  the  surface. 

The  liver  was  healthy,  so  also  the  spleen,  kidneys,  bladder,  uterus,  ovaries, 
and  the  mesenteric  glands ;  in  fact  no  disease  was  found  except  in  the  intes- 
tines. The  hernial  sac  was  empty,  and  its  opening  nearly  closed. 

In  this  case  there  was  acute  inflammation  of  the  whole  of  the 
colon,  and  of  several  feet  of  the  ileum;  the  changes  were  of  a  de- 
generative kind,  and  rapid  in  their  action.  Was  the  disease  dysen- 
tery, or  inflammation  of  a  different  kind  ?  In  the  caecum  and  colon 
we  found  that  the  solitary  glands  were  diseased,  and  that  destruction 


CATARKIIAL    INFLAMMATION    OP    THE    COLON.  379 

of  the  membrane  had  ensued ;  but  these  glands  were  not  the  only 
parts  affected,  the  follicles  and  all  the  structures  were  diseased,  as 
we  found  with  the  follicles  in  the  ileum ;  the  mucous  membrane 
and  the  muscular  coat  were  oedematous.  Very  drastic  purgatives 
and  violent  means  had  been  used  at  the  onset  of  the  disease,  and 
these  probably  contributed  to  the  severity  of  the  affection.  The 
bowels  began  to  act  very  shortly  after  the 'hernia  had  been  reduced, 
and  did  not  cease  to  act  till  death.  As  to  the  symptoms,  they  were 
those  of  dysentery ;  the  stools  consisted  of  blood  and  mucus,  the 
prostration  became  gradually  extreme,  the  pain  was  sometimes 
severe,  but  the  patient  did  not  suffer  from  the  tenderness  of  perito- 
nitis. The  disease  was  probably,  to  a  great  extent,  constitutional  in 
its  character,  but  it  was  excited  by  direct  irritation. 

CASE  CXXX.  Dysentery.  Ulceration  of  the  Small  Intestines.  Perfo- 
ration. Fecal  Abscess.  Peritonitis — Edward  B — ,  aet.  39,  was  admitted 
October  19th,  1853,  and  died  November  8th.  He  had  been  a  stout,  hearty 
man,  living  at  Walworth,  and  a  laborer  in  the  London  Docks.  His  health 
had  been  unimpaired,  and  his  habits  of  life  regular.  Six  weeks  before  admis- 
sion, he  ate  a  considerable  quantity  of  coarse  sugar,  and  three  days  afterwards 
he  had  diarrhoea,  with  copious  liquid  evacuations,  and  severe  colic.  This 
state  continued  till  admission  ;  he  had  become  thin  and  weak,  having  been 
unable  to  take  any  food  since  the  commencement  of  his  illness.  On  admis- 
sion, the  bowels  acted  every  half  hour.  The  evacuations  were  of  a  dark- 
brown  color,  and  no  blood  was  passed.  There  was  tenderness  over  the  caecum 
and  descending  colon  ;  he  had  no  appetite,  the  mouth  was  dry  and  parched, 
and  he  had  considerable  thirst ;  he  had  nausea,  but  did  not  vomit.  The 
countenance  was  dejected,  and  the  body  emaciated  and  feeble. 

The  heart  and  lungs  appeared  to  be  healthy.  The  tongue  became  very  red 
and  injected.  Great  prostration  came  on,  and  sordes  formed  on  the  teeth, 
the  purging  continuing  unabated.  Kino,  cusparia,  opium,  gallic  and  sul- 
phuric acids,  &c.,  were  administered,  with  only  slight  relief. 

Inspection  eighteen  hours  after  death.  Chest — With  the  exception  of 
calcareous  induration  at  the  right  apex,  the  thoracic  viscera  were  healthy. 
The  abdomen  was  collapsed.  The  intestines  were  contracted,  but  there  was 
universal  moderate  injection  of  the  peritoneum,  and  the  coils  of  the  intestine 
were  united  by  h'brinous  adhesions.  On  separating  the  abdominal  parietes 
from  the  sigmoid  flexure,  a  part  of  the  intestine  was  found  to  be  perforated, 
and  all  its  coats  destroyed  for  a  considerable  part  of  its  circumference ;  a 
small  fecal  abscess  had  been  formed.  At  the  caecum  also  and  rectum,  ex- 
travasation of  feces  was  only  prevented  by  external  adhesions.  The  large 
intestine  was  ulcerated  in  its  whole  length  ;  at  the  caecum  were  several  trans- 
verse patches  of  ulceration  ;  immediately  above  the  caecum  the  mucus  and 
muscular  coats  were  much  thickened,  apparently  from  older  disease;  beyond 
this  the  mucous  membrane  presented  a  large  slough,  and  nearly  all  the 
mucous  membrane  was  destroyed.  Here  and  there  were  granular  masses 
like  tubercles,  or  large  portions  which  had  become  intensely  congested,  and 
were  raised  above  the  ulcerated  surface,  giving  it  a  polypoid  appearance.  The 
sigmoid  flexure  and  rectum  were  equally  ulcerated  ;  in  some  parts  the  mucous 
membrane  only  was  destroyed,  in  others  nearly  all  the  coats.  In  the  small  in- 
testine, about  8  inches  from  the  caecum,  the  lining  membrane  was  intensely 
congested,  and  Peyer's  glands  presented  several  small  aphthous  old 
The  columnar  epithelium  was  scanty,  but  numerous  cells  like  mucus  were 


380 

observed.  The  mesenteric  glands  were  enlarged.  In  the  stomach  were 
several  points  of  arborescent  injection.  The  spleen  was  healthy  ;  the  liver 
fatty,  and  its  weight  was  4  Ibs. ;  the  gall-bladder  was  moderately  distended. 

The  destruction  of  the  mucous  membrane  of  the  colon  in  this  case 
was  very  great,  both  as  to  extent  and  depth ;  fecal  abscess  had  been 
formed  subsequent  to  the  perforation.  The  disease  lasted  nearly 
nine  weeks,  and  the  remedies  did  not  at  all  check  the  symptoms.  It 
is  probable  that  on  admission  (for  the  disease  had  then  continued 
for  six  weeks)  considerable  sloughing  of  the  colon  existed. 

There  was  no  evidence  of  any  miasmatic  influence  nor  noxious 
effluvia,  but  the  diarrhoaa  and  subsequent  dysentery  were  produced 
by  the  foolish  excess  of  the  patient. 

CASE  CXXXI.  Ulceration  of  the  Large  Intestine.  Perforation.  Sub- 
mucous  suppuration.  Pus  in  the  Portal  Vein,  and  Inflammatory  Patches 

in  the  Liver James  T — ,  set.  59  was  admitted  into  Guy's  October  12th, 

1853,  and  died  on  the  following  day.  He  was  a  laborer  in  the  London 
Docks,  and  had  had  "  bowel  complaint"  for  two  months  ;  the  symptoms  had 
gradually  become  worse,  and  a  week  before  his  death  he  was  confined  to  his 
bed  ;  he  had  repeated  purging  of  blood,  and  became  much  emaciated. 

On  admission  the  abdomen  was  tumid  and  tympanitic,  but  tolerant  of  pres- 
sure; the  skin  was  of  a  dingy  color,  an'd  the  tongue  was  red,  glazed,  and 
dry;  he  was  in  a  prostrate  condition,  and  died  the  following  morning. 

Inspection  fifty-seven  hours  after  death. — The  body  was  spare.  Chest — 
The  pleura  at  the  left  apex  presented  a  little  cartilaginous  thickening.  There 
was  a  white  patch  over  the  ventricles  of  the  heart,  the  right  side  was  distended 
with  clot,  the  left  was  empty;  the  mitral  valve  was  thickened  and  slightly 
contracted. 

The  peritoneum  was  universally  inflamed,  injected,  and  covered  with 
effused  lymph.  The  cavity  contained  dirty  fluid,  green  in  color  and  of  an 
offensive  feculent  odor.  On  turning  aside  the  large  intestine,  an  opening  was 
found  above  the  caecum.  The  whole  length  of  the  large  intestine  was  ulce- 
rated. These  ulcers  were  transverse,  and  were  generally  about  two  inches 
in  length.  The  mucous  membrane  was  ragged,  and  covered  with  a  black 
slough ;  the  circumference  of  these  ulcers  was  thickened.  In  some  parts  the 
mucous  membrane  was  quite  destroyed,  and  the  intervening  portions  of 
mucous  membrane  were  oedematous.  The  peritoneal  surface  of  the  large 
intestine  was  observed  to  be  here  and  there  of  a  yellow  color;  on  making  a 
section  at  these  parts,  the  subserous  coat  was  found  to  be  infiltrated  with  pus 
extending  from  the  submucous  coat.  These  abscesses  were  situated  on  the 
mesenteric  side  of  the  intestine.  The  mucous  and  muscular  coats  of  the 
rectum  were  much  thickened,  and  at  the  lower  part  of  the  descending  colon 
was  a  puckered  portion  of  intestine,  ecchymosed  and  injected. 

The  small  intestines  were  healthy.  The  stomach  presented  partial  injec- 
tion. The  spleen  and  kidneys  were  healthy.  The  liver  showed  a  thickened 
layer  of  peritoneum  at  its  lower  border  (attrition).  On  the  convex  surface 
of  the  right  lobe  was  an  irregular  congested  portion  about  one  inch  in  dia- 
meter, and  at  its  centre  was  a  branch  of  the  portal  vein  filled  with  pus. 
Glisson's  capsule  was  thickened;  no  apparent  disease  of  the  trunk  of  the 
portal  vein  nor  of  the  inferior  mesenteric  vein  existed ;  the  liver  generally 
was  fatty;  weight  3  Ibs.  10  oz. 

This  was  one  of  the  most  severe  cases  of  inflammation  of  the  in- 
testine that  I  have  seen  ;  large  ragged  abscesses  extended  throughout 


com- 


CATARRHAL   INFLAMMATION    OF    THE    COLON. 

the  colon,  and  had  led  to  perforation  and  to  peritonitis.  The  - 
mencing suppuration  in  the  liver,  and  the  pus  in  the  portal  vein 
were  confirmatory  of  the  views  first  propounded  by  Dr.  Budd  and 
now  generally  admitted,  as  to  one  of  the  causes  of  abscess  of  the  liver 
When  admitted  into  Guy's  the  patient  was  in  a  dying  condition  but 
the  disease  had  existed  for  two  months. 

CASE  XXXII.  Dysentery.  Perforation  of  Colon  __  Sarah  W—  ,  set.  34, 
was  admitted  into  Guy's  Hospital  April,  1874,  after  having  been  ill  for  three 
months,  and  severely  so  for  three  weeks.  She  had  resided  at  Huntingdon, 
then  at  Lambeth,  and  was  the  wife  of  a  fishmonger.  Three  months"  pre- 
viously she  had  had  pitchy  evacuations,  evidently  containing  blood;  but  she 
had  been  free  from  pain.  Three  weeks  before  admission  she  had  profuse 
purging;  the  evacuations  contained  blood,  and  scarcely  any  solid  feces  ;  she 
suffered  much  tenesmus  and  general  pain  in  the  abdomen;  the  pain  was 
occasionally  aggravated,  but  was  especially  situated  in  the  right  iliac  fossa. 
Scybala  were  occasionally  passed.  There  was  febrile  excitement,  and  before 
death  vomiting  came  on. 

She  took  opium  alone,  then  lead,  ipecacuanha,  and  copper;  mercurial  in- 
unction was  used;  leeches  and  blisters,  &c.,  were  applied  to  the  abdomen. 
Wine  and  suet  and  milk  were  administered. 

Inspection  —  The  body  was  well  nourished,  and  there  was  a  considerable 
amount  of  fat  in  the  abdominal  parietes.  On  opening  the  peritoneum,  it  was 
found  to  be  exceedingly  dry;  the  transverse  colon  was  adherent  to  neighboring 
viscera  by  soft  adhesions;  the  omentum  extended  to  the  pelvis,  and  on  raising 
it  soft  adhesions  were  found  between  it  and  the  intestine,  which  were  also 
much  injected  at  their  points  of  contact  with  each  other.  In  the  left  iliac 
region,  on  drawing  aside  the  sigmoid  flexure,  soft  adhesions  gave  way,  and 
a  small  circular  perforation  was  found;  no  extravasation  had  taken  place. 
In  the  right  iliac  fossa,  the  caecum  was  more  firmly  adherent  ;  and  close  to 
the  union  of  the  vermiform  appendix  a  long  defined  opening  was  observed, 
but  closed  by  adhesions. 

There  were  also  several  perforations  in  the  ascending  and  transverse  colon 
similarly  closed;  in  other  parts  the  peritoneum  only  was  left.  Perforations 
had  also  taken  place  in  the  rectum,  but  no  extravasation  had  followed  from 
any  part.  The  vermiform  appendix  was  healthy.  The  caecum  and  ascending 
colon  were  distended  and  thickened. 

On  opening  the  whole  length  of  the  large  intestines,  the  following  appear- 
ances presented  themselves  :  Portions  of  mucous  membrane  which  had  escaped 
ulceration  were  softened,  and  were  of  a  greenish  or  red  color  ;  large  trans- 
verse ulcers  were  found  at  other  parts,  their  margins  were  defined  ;  in  some 
the  peritoneum  formed  the  base,  and  in  nearly  a  dozen  places  the  peritoneum 
also  was  destroyed.  Hard,  dry  scybala  adhered  in  some  parts.  About  six 
inches  above  the  caecum  the  intestine  appeared  somewhat  contracted,  and 
large  pouches  were  formed  both  above  and  below.  The  small  intestines  were 
pale  and  no  disease  was  observed  in  them  ;  they  contained  fluid  feces.  The 
mucous  membrane  of  the  stomach  was  thickened  and  softened.  The  liver 
was  pale  and  soft.  The  gall-bladder  was  much  contracted  and  adherent  to 
the  colon  ;  it  contained  a  small  quantity  of  white,  thick  mucus,  and  crystals 
of  cholesterine  ;  the  duct  was  blocked  up  by  a  gall-stone,  which  was  about 
half  an  inch  in  circumference.  The  spleen  was  larger  than  natural  and  it 
was  softened.  The  kidney  presented  an  irregular  contraction  on  its  surface. 

The  lungs  were  emphysematous  ;   one  or  two  consolidated  lobules  were 


382  ON    DYSENTERY    AND 

situated  at  the  apex.     The  heart  was  flabby;  but,  with  the  exception  of  slight 
atlieroma,  the  valves  were  healthy. 

In  this  case  the  most  severe  inflammation  of  the  colon  had  been 
set  up,  the  coats  of  the  intestine  had  sloughed,  and  numerous  perfo- 
rations had  resulted.  The  disease  had  lasted  for  three  months;  but 
a  short  time  before  admission  it  became  much  aggravated.  It  could 
scarcely  be  expected  that  the  administration  of  small  doses  of  astrin- 
gents could  check  such  extensive  degeneration;  and  it  was  evident 
that  the  patient  died,  not  from  exhaustion,  but  from  the  severity  of 
the  disease,  and  its  extension  to  the  peritoneum. 

CASE  CXXXIII.  Chronic  Bronchitic  Phthisis.  Cirrhosed  and  Larda- 
ceous  Liver.  Contracted  Abscess  of  Liver.  Chronic  Dysentery,  and 
Chronic  Peritonitis. — Thomas  R — ,  aet.  31,  a  soldier,  or  rather  pensioner, 
was  admitted  under  my  care  Oct.  24th,  1856.  He  had  been  in  the  West 
Indies  as  a  soldier,  and  had  been  exceedingly  intemperate  in  his  habits, 
spending  all  his  money  in  rum,  &c.  He  stated,  however,  that  till  three  years 
previously  he  enjoyed  good  health,  but  had  had  syphilis  six  or  seven  times, 
and  had  been  salivated  five  times ;  and  that  when  a  child  he  had  had  ague. 

Two  and  a  half  years  before,  while  serving  in  Bermuda,  he  was  exposed 
to  cold  at  night ;  the  following  morning  he  had  severe  cold  and  cough  ;  but 
did  not  report  himself  as  ill  for  six  months,  having  then  gradually  become 
much  worse.  At  that  time  he  spat  blood,  and  had  night  sweats,  and  had 
great  pain  in  the  precordial  region.  He  remained  in  hospital  for  nine 
months,  and  left  very  little  relieved.  He  subsequently  went  to  the  Crimea, 
but  was  at  once  invalided,  and  sent  to  Scutari.  Sixteen  days  before  his 
admission  into  Guy's  his  ankle  became  swollen,  and  dropsy  rapidly  increased. 

He  was  a  tall,  emaciated  man,  with  an  exceedingly  anxious,  haggard  ex- 
pression ;  the  nails  were  clubbed  ;  the  respiration  was  difficult  and  hurried ; 
and  he  was  almost  in  a  dying  condition.  He  complained  of  pain  in  the 
chest  and  abdomen  ;  the  respiration  was  24  per  minute,  and  he  expectorated 
much  thick,  greenish  and  rusty-colored  mucus. 

There  were  signs  of  advanced  phthisis  in  both  lungs.  The  abdomen  was 
hot  and  distended  ;  the  superficial  veins  were  enlarged ;  fluctuation  was  very 
perceptible ;  the  bowels  were  relaxed ;  urine  high-colored,  non-albuminous, 
sp.  gr.  1.012.  He  gradually  sank. 

Inspection,  Nov.  3d — The  body  was  much  emaciated.  The  abdomen  was 
distended,  but  the  enlargement  of  the  superficial  veins  had  disappeared. 
Chest — The  lungs  presented  advanced  disease,  with  some  recent  pneumonia. 

Abdomen — The  peritoneum  contained  several  gallons  of  fluid ;  the  intes- 
tines were  moderately  distended.  The  peritoneum  was  opaque,  slightly 
granular,  and  very  delicate  bands  were  found  between  the  intestine.  The 
liver  was  much  contracted,  nodulated,  and  its  surface  was  opaque.  On  sec- 
tion, an  irregular  cheesy  mass  was  found,  about  three  inches  in  length,  ex- 
tending from  the  surface  of  the  liver  into  its  substance,  and  surrounded  by 
slight  fibrinous  investment ;  the  surface  was  contracted.  This  mass  appeared 
to  consist  of  two  or  three  collections  appended  the  one  to  the  other.  There 
were  numerous  other  small  cheesy  masses  of  smaller  size,  situated  throughout 
the  liver,  in  the  course  of  the  portal  branches.  They  were  all  apparently  the 
result  of  inflammatory  action,  or  dried  abscesses.  The  rest  of  the  liver  was 
Bemi-transparent,  and  in  many  parts  was  lardaceous.  The  gall-bladder  was 
contracted.  The  spleen  was  enlarged  and  lardaceous.  The  kidneys  were 
healthy. 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  383 

Colon — The  whole  of  the  colon  presented  irregularly  healed  ulcers,  and 
was  granular  and  thickened ;  and  scarcely  any  healthy  mucous  membrane 
was  observable.  Small  circular,  smooth  spaces,  evidently  healed  ulcers, 
studded  the  whole  surface.  The  coats  of  the  intestine  were  thickened.  The 
ileum  and  stomach  were  healthy ;  so  also  were  the  kidneys.  The  omentum 
was  adherent  near  the  inguinal  canal  on  the  left  side. 

The  original  malady  appeared  to  have  been  dysentery,  contracted 
in  the  West  Indies,  and  it  was  followed  by  abscesses  in  the  liver; 
these  abscesses  dried,  and  probably  constituted  the  cheesy  masses 
found  after  death,  affording  a  remarkable  instance  of  abscess  of  the 
liver,  and  perhaps  of  pyasmia  not  at  once  fatal.  The  intemperate 
and  dissolute  habits  of  the  patient  set  up  chronic  fibroid  disease  in 
the  lungs.  The  lardaceous  state  of  the  liver  was  interesting  in  its 
connection  with  syphilis  and  struma.  The  colon  was  filled  with 
cicatrices ;  and  they  had  led  to  partial  obstruction,  as  shown  by  the 
hypertrophy  of  the  intestinal  coats. 

CASE  CXXXIV.  Chronic  Dysentery.  Hepatic  Abscess.  Pyeemia. 
Abscess  in  the  Brain  and  Lung — Thomas  D — ,  aet.  25,  was  admitted  Febru- 
ary 14th,  and  died  March  19th,  1855.  He  was  a  sailor,  and  had  been  for 
two  years  in  the  East  Indies.  At  Burmah  he  had  ague  and  dysentery, 
and  was  ill  for  several  weeks ;  and  for  two  months  he  had  had  pain  in  the 
side.  , 

On  admission,  he  was  sallow  and  generally  cachectic.  There  was  pain  in 
the  right  side  ;  the  chest  was  dull ;  and  it  was  supposed  from  the  history  that 
he  had  abscess  in  the  liver. 

On  February  21st,  when  sitting  by  the  fire,  he  fell  down  in  a  fit,  and  was 
convulsed  for  several  days ;  he  continued  in  a  semi-conscious  condition.  On 
the  28th,  he  could  speak  and  give  his  name ;  he  continued  apparently  to  im- 
prove till  the  14th,  when  he  again  fell  into  a  semi-conscious  state.  On  the 
1  Gth  he  was  able  to  sit  up  and  take  his  breakfast ;  but  shortly  afterwards 
became  quite  insensible  ;  and  had  stertorous  breathing,  which  continued  till 
death.  It  was  observed  throughout,  that  the  right  leg  was  weak,  and  at  last 
was  paralyzed ;  the  right  pupil  was  smaller  than  the  left ;  but  a  few  hours 
before  death  it  became  widely  dilated. 

Inspection  twenty-four  hours  after  death.  •  Brain. — The  surface  of  the 
hemisphere  was  dry;  and  at  the  base  were  slight  adhesions  between  the 
surfaces  of  the  arachnoid.  In  the  posterior  lobe  of  the  left  hemisphere  was 
an  abscess  about  the  size  of  a  hen's  egg,  containing  thick,  tenacious  pus ;  it 
nearly  reached  the  surface,  and  was  surrounded  with  softened  brain  sub- 
stance ;  at  the  anterior  part  of  the  abscess  was  a  clot  of  blood,  also  surrounded 
by  softened  tissue.  The  abscess  had  broken  into  the  left  lateral  ventricle  at 
its  posterior  corner;  the  left  ventricle  was  filled  with  pus ;  the  right  with 
about  3j  of  clear  serum ;  the  fourth  ventricle  was  healthy. 

In  the  chest  were  old  and  recent  adhesions  at  the  bases  of  both  pleural 
cavities.  The  bronchi  were  slightly  inflamed,  and  contained  muco-purulent 
secretion.  The  base  of  the  left  lung  contained  a  small  abscess;  the  base  of 
the  right  was  in  a  state  of  incipient  pneumonia. 

Liver In  the  right  lobe,  at  the  upper  surface,  were  two  chronic  abscesses, 

capable  of  holding  about  3'iij  of  pus;  the  pus  was  thick  and  green;  the  walls 
of  the  abscess  were  very  thick,  bounded  by  a  smooth  cyst,  and  firm  tissue 
about  one-eighth  of  an  inch  in  thickness;  on  the  circumference  of  the  abscess 
a  compressed  vein  was  observed. 


38-t  ON    DYSENTERY    AND 

In  the  colon  the  mucous  membrane  was  thickened;  several  well-marked 
cicatrices  were  found  in  the  ascending  colon ;  the  mucous  membrane  was 
puckered,  and  in  some  parts  was  of  a  slate  color  ;  the  muscular  coat  was 
slightly  hypertrophied. 

It  appears  probable  that  the  dysentery,  which  had  been  contracted 
in  Burmah,  had  led  to  abscess  in  the  liver,  and  that  this  remained 
passive  for  many  months,  producing  hectic,  with  pain  in  the  side, 
&c.,  and  at  last,  from  some  fresh  exciting  cause,  new  action  was  set 
up,  producing  acute  pyaemia,  and  abscess  in  the  brain  as  the  conse- 
quence. Dr.  Hughes  diagnosed  this  course  of  morbid  changes,  which 
was  completely  confirmed  on  inspection  after  death. 

CASE  CXXXV.  Dysentery.  Abscess  of  the  Liver.  Perforation  of  the 
Diaphragm.  Empyema — John  J — ,  set.  32,  admitted  into  Guy's  Hospital 
July  28th,  1858,  under  the  care  of  Dr.  Wilks.  Till  February,  1857,  he  had 
been  perfectly  well,  and  went  to  the  coast  of  Guinea;  during  two  months  he 
remained  on  that  coast,  and  had  dysentery,  producing  much  purging,  with 
tenesmus,  and  a  discharge  of  a  small  quantity  of  blood.  The  dysenteric 
symptoms  continued  for  two  months,  and  quite  incapacitated  him  from  work. 
The  symptoms  came  on  suddenly,  and  were  accompanied  with  severe  pain ; 
he  took  spirits  for  relief,  but  the  following  day  pain  again  returned,  with  a 
febrile  condition,  and  with  severe  headache,  &c.,  he  was  then  completely  laid 
aside,  and  for  a  month  was  unable  to  take  food.  On  June  14-th,  he  arrived 
in  London  and  had  been  under  treatment  till  application  at  the  hospital. 

He  was  a  man  of  fair  complexion,  slightly  sallow,  and  emaciated.  He 
complained  of  pain  in  the  right  side,  and  had  occasional  rigors,  but  did  not 
suffer  from  cough  ;  the  bowels  acted  regularly  ;  the  tongue  was  slightly  furred. 
The  abdomen  was  collapsed ;  but  there  was  pain  in  the  right  side  of  the 
chest,  which  was  uniformly  dull;  tubular  breathing  was  audible,  and  on  the 
left  side  puerile  respiration ;  and  it  was  evident  that  fluid  effusion  had  taken 
place  into  the  right  pleura.  One  week  before  death,  his  distress  greatly 
increased,  and  paracentesis  thoracis  was  performed,  and  a  pint  of  pus  was 
evacuated ;  he  died  August  20th. 

On  inspection,  the  right  pleura  was  found  to  be  filled  with  several  pints  of 
gray  purulent  fluid;  the  compressed  lung  being  at  the  posterior  and  upper 
part  of  the  chest;  a  large  opening  in  the  diaphragm  on  the  right  side  allowed 
free  communication  between  Ihe  pleura  and  an  abscess  situated  between  the 
liver  and  the  diaphragm ;  it  was  this  abscess  which  had  been  opened  by  the 
paracentesis.  The  left  lung  and  the  heart  were  healthy.  In  the  abdomen 
there  were  local  adhesions  between  the  intestines  in  various  parts;  at  the 
lower  part  of  the  ileum,  and  in  the  ascending  colon,  there  was  some  recent 
ulceration,  and  in  some  other  parts  a  small  quantity  of  granular  lymph  was 
found  covering  the  mucous  membrane.  In  the  crecuin  were  two  large  ulcers 
of  older  date,  with  raised  thickened  edges,  and  the  mucous  membrane  was 
destroyed;  towards  the  rectum  the  mucous  membrane  was  of  a  slate  color. 

The  large  abscess  above  the  liver  was  between  the  liver  and  the  diaphragm, 
and  the  capsule  of  the  liver  formed  part  of  the  walls  of  the  abscess ;  there 
were  several  abscesses  in  the  substance  of  the  liver  itself,  and  the  whole  of 
the  gland  was  filled  with  small  deposits  of  pus.  Many  of  the  hepatic  veins 
wen-  filled  with  clot  and  pus,  the  latter  having  apparently  entered  the  veins 
secondarily  from  the  tissue;  the  liver  weighed  (Ji  Ibs.  The  spleen  and  kid- 
neys were  healthy. 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  385 

This  was  a  case  of  great  interest.  Acute  dysentery,  which  the 
patient  had  contracted  on  the  coast  of  Guinea,  was  followed  by  hepa- 
tic abscess.  This  latter  abscess  extended  to  the  surface  of  the  liver, 
and  led  to  perforation  of  the  diaphragm;  the  symptoms  of  pleuritic 
effusion  were  then  produced,  and  led  ultimately  to  a  fatal  termina- 
tion. Dr.  Wilks  had  diagnosed  the  purulent  collection,  and  deter- 
mined to  draw  off  the  fluid:  the  trochar  passed  above  instead  of  be- 
neath the  diaphragm;'  but  since  the  communication  through  the 
diapraghm  was  perfectly  free,  the  whole  of  the  contents  of  the  abscess* 
and  of  the  pleura  could  be  emptied  at  the  same  time.  There  was 
evidence  of  old  disease  in  the  mucous  membrane  of  the  colon. 

CASE  CXXXVI.  Chronic  Ulcer ati on  of  the  Intestine.  Dysentery.  Cica- 
trization. Contraction.  Perforation.  Abscess  near  the  crest  of  the  Ileum. 
(From  the  Museum  Records) — A  young  man  of  intemperate  habits,  and 
who  had  had  syphilis,  several  years  before  death  had  a  dysenteric  affection, 
on  the  subsidence  of  which  his  bowels  were  habitually  constipated  ;  this  state 
was  attributed  to  stricture  of  the  rectum,  which  was  felt  at  no  great  distance 
from  the  anus.  A  bougie  was  passed  with  the  effect  of  considerably  dilating 
the  stricture.  He  subsequently  went  to  America,  but  he  did  not  prosper. 
The  death  of  his  wife  and  other  misfortunes  were  followed  by  declining 
health.  An  abscess  formed  above  the  crest  of  the  ileum,  towards  the  pos- 
terior part  on  the  left  side,  and  there  was  continual  pain  at  that  part ;  after 
the  application  of  leeches  several  sinuses  formed,  diarrhoea  came  on,  and  he 
wasted  rapidly. 

On  inspection,  except  pleuritic  adhesions,  the  thoracic  viscera  were  healthy. 
In  the  left  iliac  region  the  integuments  were  separated  from  the  tendon  of 
the  external  oblique  by  sinuous  ulceration.  In  that  region,  the  intestines 
Avere  glued  together ;  the  peritoneum  and  adjacent  cellular  membrane  were 
much  thickened  ;  the  rest  of  the  peritoneum  was  healthy.  In  the  sigmoid 
flexure  there  were  numerous  traces  of  old  ulceration,  of  a  lightish  green 
color,  the  surface  was  uneven,  and  the  structure  of  the  intestine  at  the  part 
was  thickened  and  condensed  ;  the  calibre  of  the  intestine  was  also  much  con- 
tracted. There  were  three  or  four  small  perforations  in  the  intestine  at  this 
part ;  the  rectum  was  healthy,  except  immediately  above  the  anus,  where  there 
was  considerable  thickening  with  induration.  This  evidently  depended  on  an 
old  ulcer,  occupying  about  half  the  intestine  ;  and  the  part  was  of  a  leaden 
color.  The  liver  was  much  enlarged  and  fatty.  The  gall-bladder  contained 
some  ropy  mucus.  The  kidneys  and  the  rest  of  the  intestines  were  healthy. 

This  case  is  a  very  interesting  one,  for  although  the  dysentery  was 
relieved,  the  cicatrization  and  subsequent  contraction  were  followed 
by  constipation ;  ulceration  was  set  up  above  the  points  of  contrac- 
tion, and  ultimately  the  intestine  was  perforated.  The  sinuses 
opened  near  the  crest  of  the  ileum ;  feces  do  not  appear  to  have  been 
discharged  ;  but  the  case  might  easily  have  been  mistaken  for  suppu- 
ration from  diseased  bone. 

The  constriction  in  these  instances  arises  from  fibro-elastic  tissue, 
which  becomes  more  dense  than  the  original  muscular  coat ;  it  closely 
resembles  that  found  after  the  destruction  of  the  skin  in  burns,  and 
has  a  similar  disposition  to  contract. 

II.  Acute  inflammation  of  the  colon  sometimes  takes  place  in  com- 
25 


386  ON    DYSENTERY    AND 

mon  with  diseases  of  other  organs;  and  these  cases  present  a  marked 
difference  from  those  previously  detailed. 

Thus  the  thoracic  viscera  are  affected  with  acute  disease;  the  bron- 
chial tubes  and  lungs  are  inflamed,  and  so,  in  fact,  are  almost  all  the 
mucous  membranes.  The  symptoms  of  disease  of  the  chest  are  more 
marked  than  those  of  the  abdomen ;  dyspnoea,  cough,  febrile  excite- 
ment are  present  with  the  physical  signs  of  thoracic  disease.  The 
countenance  is  anxious  and  flushed,  the  skin  hot  and  dry,  or  clammy  ; 
the  pulse  becomes  gradually  more  depressed,  the  tongue  brown  and 
dry,  and  the  patient  is  prostrate.  These  symptoms  are  accompanied 
by  dysenteric  diarrhoea,  which  indicates  a  diseased  state  of  the  colon. 

In  some  of  these  cases,  the  exciting  cause  of  the  inflammation  of 
the  lungs  and  bronchi  is  also  the  cause  of  like  disease  of  the  mucous 
membrane  of  the  alimentary  canal.  In  others,  the  symptoms  appear 
to  be  allied  to  those  of  pyaemia,  and  the  affection  of  the  colon  is 
merely  another  expression  of  the  morbid  state  of  the  blood ;  here 
also,  the  indications  of  inflammation  of  the  colon  are  not  well  marked. 
Nearly  all  these  cases  are  of  a  very  severe  character,  and  tend  to  a 
fatal  result. 

In  the  treatment,  the  thoracic  disease  demands  most  urgent  atten- 
tion ;  but  it  must  be  borne  in  mind,  that  the  disease  of  the  alimentary 
canal  tends  still  further  to  depress  the  powers  of  life;  and  we  must 
not  add  to  the  inflammation  there  existing,  by  the  administration  of 
powerful  drastic  purgatives. 

CASE  CXXXVII.  Dysentery.  Pneumonia.  Hydrencephaloid  Disease. 
— Charles  O — ,  aet.  32,  was  admitted  June  26,  1854,  in  an  unconscious  state. 
He  had  been  a  blacksmith  at  Brixton.  About  six  months  previously,  while 
at  work,  he  was  seized  with  a  fit,,  which  deprived  him  of  speech  for  half  an 
hour,  when  he  returned  to  his  work  ;  and  from  that  time  he  suffered  from 
pain  in  his  head.  At  one  time  he  was  very  sleepy  and  unable  to  work  ;  at 
other  times  he  became. excited,  and  his  speech  was  affected.  He  continued 
more  or  less  at  work  till  ten  days  before  admission,  when  he  seemed  quite 
lost,  and  he  was  taken  home  from  his  employment.  He  complained  of  pain 
in  his  head  and  of  giddiness,  and  was  said  to  be  suffering  from  inflammation 
of  the  brain,  and  was  bled.  His  symptoms  increased,  and  when  admitted  he 
spoke  incoherently,  and  threw  his  arms  and  head  about.  He  placed  his  hand 
on  his  head,  as  if  he  suffered  there.  He  was  very  pale,  which  was  attributed 
to  loss  of  blood  ;  the  pupils  were  dilated,  and  he  had  dysenteric  diarrhoea. 
For  the  next  seven  days  he  gradually  became  more  prostrate ;  he  seemed  for 
a  moment  to  return  to  consciousness,  and  then  relapsed  into  an  insensible 
condition.  July  3d.  He  was  able  to  speak  rationally ;  the  right  pupil  was 
contracted,  but  the  left  was  dilated ;  he  appeared  paralyzed,  but  continued 
sensible  till  his  death,  on  the  5th. 

Inspection,  eighteen  hours  after  death.  Brain There  was  an  increased 

amount  of  clear  serum  in  the  membranes  on  the  surface  of  the  brain.  The 
brain  substance  was  very  pale  and  watery,  its  weight  2  Ibs.  14^  ozs. ;  no 
tubercle  was  discoverable.  The  ventricles  contained  an  excess  of  fluid,  3  or 
4  drachms  each  ;  the  central  parts  were  not  softened  ;  the  microscope  showed 
no  inflammatory  corpuscles.  There  were  a  few  purpuric  spots  on  the  pleura. 
The  lower  lobe  of  the  right  lung  was  in  a  state  of  red  hepatization,  heavy, 
soft,  and  ocdematous.  Both  apices  contained  a  few  groups  of  tubercles. 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  387 

Heart  healthy.  The  whole  of  the  large  intestine,  from  the  caecum  to  the 
rectum,  was  in  a  state  of  acute  inflammation.  In  the  transverse  colon  were 
isolated  ragged  ulcers  ;  these  were  close  together  in  the  ca?cum.  In  the  sig- 
moid  flexure  and  in  the  rectum  the  whole  surface  was  ulcerated,  and  covered 
with  a  thick  membranous  exudation ;  the  muscular  coat  in  some  parts  was 
thickened.  The  spleen  and  liver  were  healthy  ;  the  kidneys  were  large  and 
coarse  ;  the  bladder  presented  a  few  spots,  purplish  in  color  and  ulcerated  in 
the  centre. 

CASE  CXXXVIII.  Diphtherite  of  the  Caecum  and  Colon.  Bronchitis. 
Pneumonia.  Cirrhosis — Charles  G — ,  ast.  34,  was  admitted,  March  8th, 
1854.  He  was  a  tall  man,  of  dark  complexion,  and  intemperate  in  his  habits 
of  life.  For  three  years  he  had  served  as  a  soldier  in  the  East  Indies.  Five 
days  before  admission  he  was  taken  ill,  with  febrile  symptoms,  cough,  pain 
in  his  side,  and  dark-colored  expectoration ;  dropsical  effusion  came  on,  and 
subsequently  jaundice.  When  first  seen  he  was  prostrate,  comatose,  and 
restless ;  the  lips  were  dry  and  cracked ;  there  were  sordes  on  the  tongue ; 
the  skin  was  hot  and  dry,  and  slightly  jaundiced  ;  the  pulse  was  156.  There 
were  symptoms  of  pneumonia;  pain  was  produced  by  pressure  on  the  abdo- 
men, and  there  were  a  few  petechial  spots.  He  became  more  comatose 
before  death. 

Inspection,  eight  and  a  half  hours  after  death.  The  body  was  jaundiced ; 
numerous  spots  of  purpura  were  observed  on  its  surface,  and  on  the  leg  was 
a  chronic  ulcer.  The  trachea  and  right  bronchus  were  granular  and  con- 
gested. The  lungs  did  not  collapse ;  the  right  was  covered  with  a  delicate 
layer  of  lymph,  the  lower  lobe  was  granular,  consolidated,  and  of  a  yellow 
color  at  the  lower  part.  The  left  lung  was  healthy,  but  its  lower  lobe  was 
much  congested.  Over  the  left  ventricle  of  the  heart  was  an  old  adhesion, 
about  the  size  of  half  a  crown ;  the  heart  was  thirteen  ounces  in  weight,  but 
otherwise  healthy.  The  whole  of  the  mucous  membrane  of  the  stomach, 
ileum,  caecum,  and  colon,  were  much  congested  ;  this  congestion  at  the  caecum 
and  colon  became  intense,  and  the  folds  were  everywhere  covered  over  with 
a  delicate  diphtheritic  layer.  The  liver  was  covered  with  false  membrane  ; 
it  was  contracted,  partially  cirrhosed,  and  very  firm,  and  was  much  congested 
with  bile.  The  gall-bladder  contained  3-*  °f  bile-  The  8Pleen  was  laroe> 
soft,  and  pale,  weighing  2£  Ibs.  The  kidneys  also  were  large,  and  much 
congested. 

CASE  CXXXIX.  Inflammation  of  the  Colon  and  Rectum  with  false  Mem- 
brane,  and  superficial  Ulceration,  $c.  Pneumonia.  Entericat — James 
S— ,  set.  20,  was  a  laborer  on  the  Sydenham  Railway,  who  had  lodged  at 
Norwood ;  his  habits  had  been  temperate ;  and  his  general  health  good ;  he 
was  brought  to  Guy's  July  18th,  1855.  One  month  previously  he  had  been 
wet  through,  and  experienced  pain  in  his  head  and  back  ;  a  week  afterwards 
cough  came  on,  and  mucus  was  expectorated  with  blood,  and  these  symptoms 
increased  till  admission.  His  countenance  was  anxious  and  flushed,  his 
pupils  dilated,  the  skin  hot  and  dry,  the  tongue  was  covered  with  a  thick  fur; 
the  expectoration  was  viscid,  tenacious,  yellow,  and  rust-colored  ;  p^se 
He  was  neatly  depressed,  lying  on  his  back,  and  had  tremor  of  the  hands 
and  tongue,  with  occasional  delirium.  He  had  severe  diarrhea ;  there  was 
dulness  of  the  chest,  especially  of  the  left  lung,  with  general  submucous  crepi- 
tation. He  had  the  appearance  of  a  person  affected  with  typhoid  fever,  but 
without  the  cerebral  oppression.  The  symptoms  of  acute  pneumonia  becam 
more  marked,  with  rusty  sputum  and  low  muttering  delirium. 


388 


OV    DYSENTERY    AND 


The  prostration  increased,  and  the  parent  gradually  sank  ;  he  died  August 
3d.  There  were  no  maculae  on  or  after  admission  ;  the  diarrhoea  did  not  con- 
tinue after  the  first  few  days,  nor  was  any  blood  discharged  with  the  motions. 

Inspection,  August  6.  The  body  was  of  moderate  stature.  Chest — On 
the  right  side  there  was  an  effusion  of  fibrin,  and  about  a  pint  of  bloody  puru- 
lent serum  in  the  pleural  sac.  The  lower  lobe  of  the  right  lung  was  com- 
pressed, the  upper  pneumonic  ;  the  left  pleura  also  was  quite  free  from  adhe- 
sions ;  the  lower  lobe  was  in  a  state  of  pulmonary  apoplexy,  the  upper  part 
of  the  same  lobe  was  very  much  congested  and  consolidated  :  it  sank  in 
water.  The  pericardium  contained  several  ounces  of  bloody  serum ;  the 
heart  was  flabby,  but  was  otherwise  healthy.  The  abdomen  was  moderately 
distended  ;  the  peritoneum  was  smooth  and  healthy  ;  the  stomach  presented 
advanced  gastric  solution,  the  mucous  membrane  at  the  cardiac  extremity 
being  exceedingly  thin  ;  the  small  intestine  contained  yellow,  bilious  fluid 
feces ;  in  the  last  foot  of  the  ileum  the  mucous  membrane  was  gray,  Peyer's 
patches  were  slightly  raised,  and  in  a  few  parts  presented  irregular  ulcera- 
tion  ;  they  had  not,  however,  the  raised  swollen  appearance  common  in 
enteric  fever.  The  caecum  contained  several  small  ulcers,  and  the  whole 
mucous  membrane  was  of  an  iron-gray  color  ;  the  edges  of  most  of  these 
ulcers  were  smooth  and  contracting ;  the  mucous  membrane  was  thickened. 
In  the  transverse  and  descending  colon  and  in  the  rectum  the  whole  of 
the  mucous  membrane  had  a  swollen,  oedematous  and  almost  viilous  appear- 
ance ;  this  was  most  marked  towards  the  rectum.  Studding  the  swollen 
membrane  with  white  patches  of  adherent  lymph,  in  some  parts  merely  con- 
stituting a  thin,  delicate,  but  adherent  membrane,  in  others  forming  a  large 
flocculent  mass  about  three-quarters  of  an  inch  in  length,  firmly  adherent  to 
the  membrane  ;  there  were  numerous  small  ulcers  scattered  over  these  por- 
tions of  the  intestine  ;  some  with  smooth,  others  with  irregular  and  congested 
margins ;  some  contained  a  small  portion  of  false  membrane,  like  a  slough  ; 
from  others  large  masses  of  false  membrane  could  be  detached.  On  tearing 
off  portions  of  this  membrane,  an  injected  granular  surface  or  superficial 
ulceration  was  observed.  The  submucous  cellular  tissue  was  white,  thick- 
ened, and  oeJematous ;  the  muscular  coat  was  contracted  and  distinct,  and 


Appearanre  of  inflamed  colon;  (a)  false  membrane  composed  of  granule  cells;  (b)  surface  of  a 
portion  of  the  colon  beueath  the  false  membrane  ;  (e)  fullicle  or  crypt  containing  cells  similar  to 
those  compoi,ing  the  false  membrane. 

nearly  one-eighth  of  an  inch  in  thickness ;  the  mesenteric  glands  were  en- 
larged. On  carefully  examining  portions  of  the  false  membrane,  it  was  found 
to  consist  of  granular  cells  closely  matted  together  with  very  little  blastema ; 
the  cells  were  large  and  full  of  granules,  some  contained  a  faintly  marked 
nucleus ;  but  scarcely  any  columnar  epithelium  was  observed.  On  examin- 
ing the  mucous  membrane  itself,  small  excavations  were  found  to  contain 
similar  cells.  The  liver  and  spleen  were  healthy. 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  889 

This  diseased  condition  of  the  colon  had  led  to  the  effusion  of  a 
fibrin,  and  to  the  production  of  inflammatory  cells,  instead  of  the 
ordinary  columnar  epithelium;  the  follicles  and  solitary  glands  had 
become  inflamed,  and  a  subsequent  continuation  of  this  action  pro- 
duced superficial  ulceration.  The  disease  was  of  an  inflammatory 
character,  and  not  only  the  follicles  and  glands,  but  the  whole  sur- 
face of  the  mucous  membrane  was  affected;  the  membrane  thus 
formed  appeared  more  cellular  than  is  sometimes  observed. 

The  symptoms  closely  resemble  those  of  enteric  fever  or  typhoid 
pneumonia.  The  irritation  of  the  large  intestine,  as  indicated  by 
the  diarrhoea,  appeared  to  be  checked  by  the  Dover's  powder  which 
was  given.  The  administration  of  alcoholic  stimulants  in  a  case  of 
this  kind  is  a  question  of  great  difficulty ;  the  general  symptoms — 
failing  pulse,  subsultus,  &c. — appeared  to  require  their  free  use. 
This  case  strongly  favored  the  idea  of  a  constitutional  origin  of  the 
disease,  which  resembled,  if  it  were  not  identical  with,  enteric  fever. 

III.  Another  class  of  cases  are  those  in  which  chronic  disease  has 
slowly  advanced  for  months  or  for  years ;  acute  inflammation  of  the 
alimentary  canal  is  then  set  up,  which  in  a  short  time  leads  to  a 
fatal  termination.  Cases  of  this  kind  are  not  of  unfrequent  occur- 
rence, in  which  a  patient  is  already  broken  down,  as  by  incipient 
phthisis ;  there  is  already  a  disposition  to  the  ulcerative  disease  of 
the  small  intestine,  so  common  in  phthisis,  when  probably  from  fresh 
exciting  cause,  acute  inflammatory  disease  is  set  up,  and  diarrhoea, 
which  can  scarcely  be  checked  by  any  means,  is  rapidly  fatal.  This 
inflammation,  and  the  effusion  of  false  membrane,  may  be  confined 
to  the  rectum  or  descending  colon,  or  it  may  be  found  in  the  caecum 
and  ileum.  Several  cases  of  this  kind  have  already  been  detailed  in 
connection  with  strumous  disease  of  the  intestine. 

Catarrh  of  the  Colon.1 — The  mucous  membrane  of  the  large  intes- 
tine may  be  affected  with  catarrhal  inflammation  resembling  that 
which  we  have  already  mentioned  as  occurring  in  the  small  intes- 
tine.  It  is  seen  both  as  an  acute  and  as  a  chronic  disease.  In  the 
acute  disease  the  mucous  membrane  is  congested,  and  sometimes  the 
colon  is  deeply  red  ;  one  part  only  of  the  bowel  may  be  thus  affected, 
the  caecum,  or  the  sigmoid  flexure,  or  the  rectum  ;  the  follicles  of  the 
intestine  become  enlarged  ;  the  mucous  membrane  is  swollen,  arid  the 
mucus  altered  in  character ;  the  feces  a*  first  adhere  to  the  membrane, 
for  the  secretion  is  diminished,  afterwards  the  quantity  of  mucus  is 
greatly  increased,  and  it  is  recognized  in  post-mortem  examination 
upon  the  mucous  membrane,  and  during  life  is  seen  to  coat  the  feces, 
or  to  be  passed  in  abundance  without  the  ordinary  alvine  discharge 
in  gelatiniforrn  masses,  or  in  shreds.  Ulceration  may  ensue  in  small 
patches,  or  in  a  deeper  and  more  distinct  form. 

In  chronic  catarrh,  the  mucous  membrane  is  found  to  be  thickened 
but  sometimes  it  is  atrophic  and  thin ;  the  color  may  be  gray,  and 
we  often  find  that  a  deep-colored  gray  zone  may  be  found  aro 

•  See  'Remarks  on  Catarrhal  Inflammation'  in  chapter  on  "Enteritis  and  Diar- 
rhoea." 


390  ON    DYSENTERY    AND 

the  follicles ;  due  to  pigmental  deposit  the  result  of  long-continued 
congestion.  The  mucus  secretion  varies  according  to  the  severity 
and  the  chronic  character  of  the  complaint.  The  discharge  may  be 
in  small  pieces,  or  it  may  constitute  casts  more  or  less  complete  of  a 
portion  of  the  intestine.  These  casts  may  be  several  inches  or  even 
a  foot  in  length, 'and  consist  of  mucus  cells  in  a  tenacious  albuminous 
basis,  these  casts  and  shreds  especially  in  acute  disease  may  have  a 
fibrillated  appearance  when  examined  under  the  microscope ;  the 
patient  not  unfrequently  regards  the  mucous  cast  as  the  mucous 
membrane  itself,  or  as  an  intestinal  worm. 

Symptoms. — In  acute  catarrh  the  symptoms  are  those  of  diarrhoea, 
sometimes  with  tenesmus,  when  the  rectum  is  affected,  and  then  even 
with  the  discharge  of  blood ;  there  may  be  febrile  excitement,  and 
uneasiness  in  the  abdomen,  but  in  many  cases  there  is  no  fever,  the 
tongue  may  be  clean,  the  skin  cool,  and  the  pulse  quiet ;  if  the  ex- 
creta be  irritating,  there  is  often  a  good  deal  of  smarting  pain  at  the 
orifice,  and  the  mucous  membrane  may  be  protruded..  Flatulent 
distension  of  the  abdomen  and  dyspnoea  are  also  observed. 

In  chronic  catarrh,  diarrhoea  is  usually  the  prominent  symptom ; 
it  may  continue  in  varying  degrees  for  months  or  even  for  years, 
and  it  often  alternates  with  constipation ;  if  the  strength  fail,  then 
the  pulse  becomes  compressible,  and  the  tongue  dry  and  brown  or 
glazed.  When  the  rectum  is  affected,  as  it  generally  is,  when 
mucous  casts  are  passed,  the  pelvic  viscera  closely  sympathize  with 
the  morbid  action ;  in  men  we  find  irritation  of  the  bladder,  in 
women  disturbance  of  the  uterus,  vagina  and  ovaries,  as  well  as  of 
the  bladder.  This  sympathy  is  observed  in  young  children,  acute 
catarrh  of  the  rectum  may  be  the  cause  of  vaginitis,  and  lead  to  the 
supposition  that  the  child  has  been  maltreated.  We  would,  how- 
ever, remark  that  the  converse  is  also  true,  that  stricture  and  disease 
of  the  bladder  and  prostate  will  in  men  set  up  excessive  irritation 
even  resembling  dysentery;  and  in  women,  dysmenorrhcea,  and 
ovarian  congestion  may  be  the  cause  as  well  as  the  result  of  inflam- 
mation in  the  rectum. 

The  patients  who  suffer  from  this  chronic  discharge  of  mucus  are 
generally  in  a  cachectic  state,  pale,  and  more  or  less  emaciated ;  the 
bowels  are  irregular,  sometimes  confined,  at  other  times  affected 
with  diarrhoea ;  and  there  are. occasionally  intervals  of  several  weeks 
or  months  between  these  mucous  discharges  of  flakes  and  casts. 
During  their  passage  a  sense  of  distress  and  faintness,  and  even  actual 
syncope  may  be  produced,  with  severe  colic;  the  pulse  is  compres- 
sible, the  tongue  may  be  clean  or  furred,  and  the  appetite  uncertain; 
the  rnind  is  generally  irritable  or  dejected,  and  sometimes  almost 
melancholic  and  hypochondriacal. 

The  neuralgia  is  often  very  severe,  sometimes  coming  on  two  or 
three  hours  before  the  bowels  act,  at  other  times  following  the  motion. 
The  pain  also  is  great,  it  may  extend  up  the  spine  or  pass  into  the 
pubes ;  sometimes  it  is  compared  to  the  cutting  of  an  instrument,  at 
other  times  the  sense  is  that  of  painful  burning.  These  painful  sen- 
sations may  be  quite  independent  of  any  pressure  at  the  anus,  and 


CATARRHAL    INFLAMMATION    OF    THE    COLON.  391 

may  continue  in  a  more  severe  form  after  the  primary  irritation  in 
the  bowels  has  subsided.  The  disease  is  often  very  obstinate  and  it 
may  last  not  only  for  months,  but  even  years. 

As  to  the  causes  of  this  disease,  if  seems  in  some  instances  to  be 
produced  by  catarrh  commencing  in  the  small  intestine,  or  it  may 
be  the  sequence  of  acute  or  chronic  dysentery.  The  irritation  of  a 
polypoid  growth  in  the  rectum  or  in  the  sigmoid  flexure  may  induce 
it,  or  the  mischief  may  be  due  to  the  irritation  of  hemorrhoids.  The 
portal  congestion  often  associated  with  malarious  fevers  predisposes 
to  this  form  of  mucous  congestion.  Sometimes  hard  retained  feces 
may  set  up  catarrhal  irritation,  so  that  mucus  in  considerable  quan- 
tities may  be  passed,  or  thin  feces ;  in  these  cases  there  is  a  constant 
and  painful  effort  to  evacuate  the  bowels,  and  the  malady  is  mis- 
taken for  diarrhoea  or  dysentery. 

In  those  instances  which  do  not  proceed  from  disease  of  the  rectum 
or  of  the  sigmoid  flexure,  as  haemorrhoids,  polypus,  &c.,  nor  are  the 
sequence  of  acute  dysentery,  we  have  generally  found,  either  that 
long-continued  congestion  of  the  vena  portae.  or  irritation  of  the 
urino-genital  organs  has  produced  or  at  least  perpetuated  the  disorder. 
In  young  women,  it  may  be  induced  by  painful  menstruation  and 
ovarian  disease:  in  men,  by  prostatic  disease,  calculus,  &c. 

The  disease  is  a  remedial  one,  and  the  prognosis  may  be  favorable 
when  the  irritating  causes  can  be  removed,  when  a  patient  will 
submit  to  well-regulated  dietetic  regimen  and  careful  habits  of  life, 
and  when,  for  a  sufficient  time,  he  will  persist  in  the  use  of  proper 
medicinal  measures.  - 

Where  disease  of  the  rectum  is  present,  and  local  and  general 
means  are  unavailing,  the  help  of  the  surgeon  may  be  required  to 
remove  an  irritating  growth  or  haamorrhoid.  If  the  latter  be  present, 
the  bowels  should  be  regularly  acted  upon  by  the  confection  of  senna 
and  of  black  pepper ;  the  gall  ointment  may  be  locally  applied  or  we 
may  use  an  astringent  wash;  at  the  same  time  the  diet  must  be 
carefully  regulated  and  hepatic  congestion  avoided.  It  is,  however, 
to  the  chronic  form  of  mucous  discharge  that  we  here  especially 
refer,  and  in  this,  careful  attention  to  the  diet  and  to  the  state  of  the 
skin  is  especially  needed  ;  a  nourishing  but  unstimulating  diet  should 
be  taken,  and,  if  possible,  stimulants  altogether  avoided.  Although 
mercurial  medicines,  in  aperient  or  in  very  small  'doses,  sometimes 
afford  considerable  temporary  relief,  we  have  often  found  the  distress 
greatly  increased  by  them  ;  and,  we  have  seen  greater  benefit  accrue 
from  the  use  of  nitro-hydrochloric  acid  with  henbane  and  vegetable 
infusions,  as  of  calumba  or  carscarilla.  If  the  bowels  be  loose,  kra- 
meria,  with  ipecacuanha  and  tincture  of  catechu,  may  be  used,  or 
quinine  with  Dover's  powder.  When  aperients  are  necessary,  a 
small  dose  of  colocynth  may  be  given  with  Dover's  powder,  or  of 
castor  oil  with  tincture  of  rhubarb,  but  aloes  and  the  more  powerful 
purgatives  are  injurious.  The  sulphur  confection  or  the  compound 
confection  of  senna  may  be  used ;  but  enema  of  oil  with  gruel,  or 
decoction  of  poppies  may  be  sufficient  to  act  on  the  bowels.  Astrin- 
gent injections  are  sometimes  of  service,  but  are  unavailing  if  portal 


392      DYSENTERY    AND    CATARRHAL    INFLAMMATION    OF    COLON. 

congestion  or  pelvic  irritation  continue.  In  dysmenorrhoea  and 
ovarian  disease,  absolute  rest,  at  least  for  a  time,  is  necessary,  and 
the  avoidance  of  tight  corsets  is  indispensable.  Dr.  Clark1  recom- 
mends astringents,  as  alum,  the  pernitrate  and  the  sesquichloride  of 
iron,  &c.,  but  it  is  often  better  to  soothe  the  irritated  mucous  mem- 
brane by  the  injection  of  borax  with  poppies,  or  of  nitrate  of  bismuth 
with  morphia  and  gruel,  or  morphia  suppositories  with  belladonna 
may  be  used.  If  hardened  feces  be  retained  they  must  be  got  rid  of 
by  the  use  of  gentle  aperients,  or  by  the  injection  of  several  ounces 
of  oil  followed  by  soap  and  water,  but  if  necessary  they  must  be 
removed  mechanically. 

•  See  some  interesting  remarks  on  this  subject  by  Dr.  Andrew  Clark,   'Lancet,' 
December,  1847. 


393 


CHAPTER   XIII. 

ON  TYPHOID  DISEASE  OF  THE  INTESTINE. 

IN  enteric  fever  diseased  action  of  a  special  kind  takes  place  in 
the  glands  of  the  intestine.  This  state  passes  through  very  definite 
conditions,  and  has  been  described  by  Eokitansky  as  the  typhoid 
process.  Dr.  Stewart,  Sir  W.  Jenner,  and  others  have  pointed  out 
the  essential  difference  in  the  signs  of  typhoid  and  typhus  fever,  and 
that  it  is  only  in  the  former  disease  that  we  find  an  abnormal  condi- 
tion of  the  intestine.  The  glands  especially  affected  are  those  at 
the  lower  part  of  the  ileum,  namely,  Peyer's  or  the  aggregate  glands; 
the  solitary  glands  also  become  involved,  and  the  lymphatic  glands 
of  the  mesentery  are  enlarged,  congested,  and  swollen.  The  ques- 
tions naturally  arise,  In  what  does  this  state  consist?  Is  it  a  neces- 
sary sign  of  fever?  What  are  the  indications  of  the  typhoid  state 
of  the  glands,  and  what  is  the  course  which  the  disease  pursues? 

The  intestinal  disease  consists  in  an  abnormal  and  excessive  growth 
in  the  glands  just  mentioned,  and  the  product  effused  is  composed  of 
a  blastema,  which  as  it  undergoes  but  little  development  quickly 
degenerates,  and  consists  of  an  immense  aggregation  of  granules, 
and  of  some  large  cells  containing  nuclei. 

Soon  after  the  commencement  of  the  fever  the  glands  are  swollen 
and  enlarged,  and  the  mucous  membrane  becomes  more  vascular 
than  usual.  As  the  fever  advances  the  glands  are  raised  sometimes 
two  or  three  lines  above  the  surface  of  the  membrane;  about  the 
fourteenth  day  of  fever  the  product  either  becomes  absorbed,  or 
ulceration  takes  place,  or  the  gland  sloughs;  a  few  days  later  the 
slough  is  found  to  have  separated,  and  an  irregular  nicer  occupies 
its  position;  the  muscular  coat  is  exposed;  and  the  margin  of  the 
ulcer  is  ragged  and  congested.  If  the  patient  do  well,  this  ulcera- 
tion, of  greater  or  less  extent,  gradually  heals,  a  cicatrix  is  formed, 
and  the  health  is  slowly  restored ;  the  convalescence  extends  over 
several  weeks,  and  is  interrupted,  it  may  be,  by  relapses  consequent 
on  this  condition  of  the  intestine,  or  by  a  repetition  of  the  process  in, 
hitherto  unaffected  glands.  The  glands  nearest  to  the  ileo-cohc 
valve  are  those  which  are  most  severely  affected;  and  sometimes 
the  whole  valve  itself  is  converted  into  a  slough,  and  the  disease 
extends  to  the  glands  in  the  caecum. 

The  mesenteric  glands  slowly  assume  their  normal  condition;  but, 
in  some  instances,  the  hyperaemia  thus  induced  tends  to  the  excessive 
development  of  cellular  structure,  which  may  undergo  caseous  de- 
generation. 

In  the  examination  of  the  intestines  after  death  from  fever,  we 
find  the  process  of  glandular  disease  in  various  stages  in  the  same 


304  ON    TYPHOID    DISEASE    OF    THE    INTESTINE. 

subject;  the  glands  may  be  merely  swollen  and  raised,  or  the  slough- 
ing process  may  have  commenced  in  small  points,  or  the  whole  of 
the  glands  may  be  converted  into  sloughs,  which  are  partially  de- 
tached, and  stained  by  feces;  the  glands  nearest  to  the  caecum  may 
be  in  this  latter  state,  whilst  others  further  removed  from  that  part 
are,  in  earlier  stages  of  the  same  process,  either  beginning  to  slough 
or  merely  swollen  and  raised.  In  some  cases,  when  death  has  taken 
place  several  months  after  fever,  we  have  found  cicatrices,  without 
ulceration;  the  disease  had  been  cured.  A  very  interesting  case  of 
this  kind  occurred  at -Guy's  Hospital  under  the  care  of  Sir  Win. 
Gull.  A  young  man  was  admitted,  having  the  ordinary  symptoms 
of  enteric  fever,  with  the  indications  of  ulceration  of  the  intestine; 
he  appeared  to  convalesce  favorably,  but  about  three  months  after- 
wards he  was  seized  with  typhus,  and  died  in  a  few  days.  On  in- 
spection, there  was  no  injection  of  the  mucous  membrane  of  the 
ileum,  but  only  cicatrices. 

As  a  consequence  of  this  diseased  action  the  whole  of  the  mucous 
membrane  and  even  the  deeper  tissues  become  inflamed;  the  intes- 
tine, from  its  enfeebled  muscular  power,  readily  yields  to  any  dis- 
tending force;  the  peritoneum  is  sometimes  injected,  and  we  find  in 
many  cases  a  delicate,  fibrinous  exudation  upon  it;  again,  the  mucous 
coat  often  becomes  ulcerated,  so  also  the  muscular,  till  at  last  only 
the  semi-transparent  peritoneum  is  left ;  this  also  in  many  instances 
sloughs,  and  a  minute  opening  takes  place  in  the  peritoneum,  leading 
to  rapidly  fatal  peritonitis;  and  even  when  the  peritoneum  is  not 
actually  perforated,  transudation  is  frequently  found  to  take  place, 
so  as  to  produce  acute  disease  of  the  serous  membrane. 

Tuberculosis,  although  not  a  necessary  sequence,  frequently  follows 
this  fever;  changes,  such  as  those  just  referred  to,  may  take  place  in 
the  mesenteric  glands ;  tubercles  may  be  deposited  in  the  substance 
of  the  mucous  membrane,  and  ulceration  follow ;  tubercular  disease 
of  the  peritoneum  may  take  place;  and,  lastly,  phthisical  disease  of 
the  lungs  and  other  structures  may  supervene. 

The  symptoms  which  are  especially  associated  in  enteric  fever 
with  this  condition  of  intestine,  and  which  alone  have  to  be  con- 
sidered in  this  work  on  abdominal  diseases,  are  that  the  abdomen  is 
full  and  rounded,  and  on  pressure  in  the  region  of  the  caecum  a 
gurgling  sound  is  produced,  with  more  or  less  pain;  diarrhoea  is 
generally  but  not  always  present;  for  sometimes  the  bowels  are 
confined,  even  when  the  ulceration  is  severe;  the  evacuations  are  of 
loose  consistency  and  of  an  ochre  color,  and  they  often  contain  blood 
and  portions  of  sloughy  membrane;  the  pulse  is  compressible,  the 
tongue  is  red  and  injected,  and  it  becomes  dry  or  cracked;  there  is 
often  also  a  circumscribed  flush  on  one  or  other  cheek ;  the  brain, 
too,  is  more  depressed  than  in  other  cases.  If  perforation  takes 
place  there  is  sudden  severe  pain  in  the  abdomen  with  collapse,  and 
death  then  generally  ensues  in  five  to  ten  hours. 

The  symptoms  of  typhoid  fever  are  sometimes  so  slight,  even  with 
existing  ulceration  of  the  intestine,  that  the  patient  is  able  to  walk, 
and  does  not  appear  much  enfeebled.  I  well  remember  a  case  of 


ON    TYPHOID    DISEASE    OF    THE    INTESTINE.  395 

this  kind,  attending,  and  continuing  to  attend,  as  an  out-patient  at 
Guy's  Hospital  for  three  weeks,  under  the  care  of  one  of  my  col- 
leagues. About  the  twenty-third  day,  a  short  time  after  admission 
into  the  hospital,  when  I  first  saw  him,  perforation  of  the  intestine 
had  taken  place  into  the  peritoneal  cavity,  and  death  quickly  fol- 
lowed; and  in  other  cases,  when  the  severity  of  the  fever  has  passed, 
and  the  patient  has  apparently  begun  to  convalesce,  having  regained 
power  and  mental  energy,  after  some  indiscretion  of  diet,  or  an 
attempt  to  move  from  the  bed,  perforation  takes  place,  and  the 
bright,  beaming  hope  of  returning  health  is  lost  in  the  terrible  fore- 
shadowing of  speedy  death.  These  are  painful  cases,  trying  to  the 
physician,  who  has  encouraged  the  hopes  of  the  patient  and  his 
friends,  and  still  more  so  to  those  who  are  thus  deprived  of  kindred. 
Perforation  takes  place  from  the  third  to  the  sixth  week,  and  until 
this  period  is  passed  the  greatest  care  should  be  used  in  allowing 
changes  of  food,  or  increased  muscular  movements;  for  among  the 
fatal  cases  of  enteric  fever  a  large  majority  die  from  this  perforation 
of  the  intestines. 

The  hemorrhage  from  the  intestine  in  fever  may  be  exceedingly 
severe  and  generally  results  from  sloughing  at  the  affected  part  and 
from  perforation  of  minute  vessels;  it  is  in  my  experience  rarely 
fatal,1  but  it  may  lead  to  great  exhaustion  and  may  retard  convales- 
cence, sometimes  hemorrhage  is  followed  by  rapid  subsidence  of  the 
febrile  symptoms  and  by  speedy  recovery.  Ulceration,  however,  is 
not  the  only  cause  of  hemorrhage,  for  we  find  that  bleeding  some- 
times takes  place  from  the  stomach  and  from  the  kidneys,  even  in. 
cases  that  terminate  favorably. 

The  general  symptoms  and  treatment  of  fever,  and  the  question 
whether  there  be  any  essential  difference  between  typus  and  typhoid 
fever,  are  not  within  the  sphere  of  this  work ;  the  able  manner  in 
which  they  are  discussed  by  Drs.  Stewart,  Jenner,  Wilks,  Peacock, 
Murchison,  &c.,  and  earlier  by  Bretonneau,  Louis,  Broussais,  Bouil- 
lard,  Chomel,  Christison,  &c.,  render  any  mention  of  these  points 
unnecessary. 

Treatment. — The  question  may,  and  has  been  raised,  How  far  diar- 
rhoea is  beneficial ;  and  whether  we  ought  at  once  to  check  it  ?  We 
may  be  assured  that  purgatives  are  injurious,  especially  those  of  an 
active  or  drastic  character.  The  disease  of  the  intestine  has  been 
often  aggravated  by  the  injudicious  administration  in  the  early  stage, 
of  jalap  and  scammony,  of  senna,  and  the  like;  so  also  mercurials 
tends  not  only  to  increase  the  subsequent  depression,  but  to  aggra- 
vate the  ulcerative  action.  It  is  often  beneficial  to  act  on  the  bowels 
and  on  the  liver  by  a  mild  mercurial  purge,  as  gr.  iij  of  Hydrargyrum 
cum  Greta  followed  by  a  rhubarb  draught  or  by  castor  -oil,  when 
there  is  disorder  of  the  abdominal  viscera ;  but  all  irritation  of  a 
prolonged  kind  must  be  avoided.  When  the  diarrhoea  is  continuous, 
it  should  be  checked  by  enemata  of  starch,  or  by  the  administration 

1  Murchison,  however,  states  that  of  60  cases  of  hemorrhage  32  died,  or  53.33  per 

cent. 


306  ON    TYPHOID    DISEASE    OF    THE    INTESTINE. 

of  chalk  with  opium,  or  vegetable  astringents ;  but  in  reference  to  the 
use  of  opium,  it  is  well  to  be  on  our  guard,  lest  the  cerebral  oppres- 
sion be  increased  and  a  state  of  coma  be  induced  thereby.  When 
hemorrhage  takes  place,  the  acetate  of  lead  is  sometimes  of  service, 
or  vegetable  astringents,  as  kino,  catechu,  logwood,  krarneria,  or  the 
glycerine  of  tannin. 

We  must  strongly  urge  extreme  caution  in  the  return  to  solid  and 
highly  nutritious  food ;  and  equally  important  is  it  that,  during  the 
severity  of  the  fever,  and  for  many  subsequent  days,  no  muscular 
exertion  should  be  attempted,  but  absolute  rest  in  the  recumbent 
position  maintained.  The  attention  to  these  means  would  have 
saved  many  valuable  lives  ;  and  few  diseased  conditions  require  such 
constant  watchfulness  in  the  maintenance  of  rest,  and  the  frequent 
administration  of  mild  nutritious  aliments. 

Ammonia  and  serpentary  may  be  given ;  and  in  some,  quinine 
proves  of  service,  especially  where  there  is  any  sign  of  miasmatic 
influence;  but  in  other  cases  quinine  may  reduce  the  temperature 
and  promote  convalescence.  The  judicious  administration  of  wine 
in  fever  is  one  of  the  most  difficult  questions  in  practice ;  many  are 
benefited  by  it,  whilst  others  appear  to  do  well  without  it :  a  failing 
circulation,  especially  in  advanced  life,  as  shown  by  a  compressible 
character  of  the  pulse  and  a  feeble  action  of  the  heart,  show  that  its 
free  use  is  required ;  other  indications  for  the  employment  of  stimu- 
lants are  dryness  of  the  tongue,  prostration  of  strength,  a  dusky  con- 
dition of  the  skin,  the  presence  of  petechiae,  &c.  In  many  cases,  if 
too  long  postponed,  patients  will  sink,  however  freely  wine  may 
afterwards  be  given  ;  and,  on  the  contrary,  I  have  witnessed  in  others 
that  a  reduction  of  quantity,  or  the  entire  cessation  of  the  adminis- 
tration of  wine  and  ardent  spirits,  has  been  followed  by  moisture  of 
the  tongue,  and  the  abatement  of  all  the  febrile  symptoms. 

In  some  cases  of  enteric  fever  the  pyrexia  is  reduced  by  the 
cautious  use  of  cold  water,  either  as  a  bath  or  by  sponging;  but 
where  there  is  evidence  of  severe  intestinal  affection,  great  caution 
must  be  used  lest  perforation  be  induced  or  fatal  collapse  ensue. 

CASE  CXL.  Enteric  Fever.  Peritonitis Henry  H — ,  jet.  23,  died  on 

the  twenty-third  day  of  fever;  and  on  the  day  before  death  he  had  symptoms 
of  peritonitis ;  he  had  previously  had  syphilis,  and  was  in  a  cachectic  state. 

On  inspection,  there  was  acute  peritonitis;  but  no  perforation  could  be 
found;  there  was  very  extensive  ulceration  of  the  ileum  and  caecum,  affecting 
both  the  solitary  and  Peyer's  glands;  in  one  or  two  places  the  muscular  coat 
was  also  destroyed.  The  liver,  spleen,  and  kidneys  were  healthy. 

In  this  instance,  acute  peritonitis  was  set  up,  although  complete 
perforation  had  not  taken  place;  in  some  parts,  however,  the  serous 
membrane  only  was  left  entire;  and  there  can  be  little  doubt  that 
transudation  had  resulted  in  the  acute  serous  inflammation. 

CASE  CXLI.  Enteric  Fever.  Perforation  of  Intestine  in  the  Seventh 
Week — Joseph  C — ,  set.  17,  was  admitted  August  18th,  1858,  and  died  Sep- 
tember 1st.  He  had  been  residing  at  Woolwich,  and  six  weeks  before  admis- 


ON    TYPHOID    DISEASE    OF    THE    INTESTINE.  397 

sion  had  suffered  from  fever,  with  much  diarrhoea.  The  day  before  he  was 
brought  to  Guy's  he  said  to  have' had  a  discharge  of  blood  from  the  bowels. 
On  admission  he  was  pale,  emaciated,  and  almost  pulseless;  scarcely  any 
complaint  of  pain  was  made,  but  he  had  an  anxious  and  distressed  counte- 
nance ;  the  abdomen  was  moderately  distended ;  he  rallied  slightly,  but  sank 
a  week  afterwards. 

Inspection.  Chest — The  pleura  was  healthy;  the  lungs  were  pale,  and 
distended ;  the  heart  was  healthy.  Abdomen — The  intestines  were  distended ; 
the  peritoneum  contained  about  two  pints  of  offensive  pus,  which  was  collected 
in  the  depending  parts;  there  was  scarcely  any  adhesive  lymph,  and  no  adhe- 
sions; but  the  general  peritoneal  surface  was  slightly  opaque.  About  eight 
inches  from  the  caecum  there  was  a  sloughing  opening  into  the  ileum,  capable 
of  admitting  the  tip  of  the  little  finger;  and  a  second  opening  of  rather  smaller 
size  was  situated  nearer  to  the  csEcum.  On  the  mucous  surface  of  the  ileum 
at  its  lower  part,  were  the  remains  of  ulcers;  many  of  them  cicatrizing,  their 
edges  were  smooth  and  gray;  the  floor  of  the  ulcers  was  formed  in  several 
instances  by  smooth  submuscular  areolar  tissue  on  the  peritoneal  surface; 
these  remains  of  ulcers  covered  nearly  the  whole  of  this  part  of  the  intestine. 
There  were  also  several  ulcers  in  the  caecum ;  the  rest  of  the  intestine  was 
healthy.  The  liver  was  discolored  on  its  surface,  but  it  was  otherwise 
healthy;  the  spleen  was  slightly  enlarged;  the  kidneys  were  healthy. 

The  comparative  absence  of  pain  in  this  case  was  explained  by 
the  great  prostration  from  which  the  patient  suffered.  The  great 
care  required  after  typhoid  ulceration  of  the  intestine  is  shown  in 
this  instance;  for  six  weeks  had  elapsed,  and  many  of  the  ulcers  had 
healed  before  fatal  rupture  of  the  intestine  and  peritonitis  took  place. 
It  is  probable  that  injudicious  diet  or  increased  muscular  exertion 
had  led  to  the  perforation  of  the  ileum. 

CASE  CXLII.  Enteric  Fever.  Perforation  of  the  Ileum — John  C — , 
aet.  28,  was  admitted  in  a  dying  state  into  Guy's  Hospital.  He  stated  that 
he  was  well  till  the  previous  evening,  when  he  was  seized  with  acute  pain  in 
the  abdomen;  and  on  admission  he  had  the  symptoms  of  peritonitis.  He 
died  in  a  few  hours. 

On  inspection,  the  body  was  found  to  be  well  nourished.  The  abdomen 
was  distended ;  the  whole  surface  of  the  intestines  was  covered  with  fecal 
matter,  and  the  end  of  the  ileum  was  perforated ;  the  lower  part  of  the  ileum 
was  ulcerated,  as  in  typhoid  fever,  and  one  of  these  ulcers  had  given  way; 
there  was  deposit  in  Peyer's  glands,  and  the  mesenteric  glands  were  enlarged 
and  softened.  The  liver  was  healthy,  so  also  the  kidneys.  The  spleen  was 
large,  soft,  and  of  a  dark  color. 

The  patient  seemed  to  have  been  so  far  convalescent  from  a  mild 
attack  of  fever  as  to  consider  himself  well,  when  fatal  perforation 
of  the  ileum  took  place.  The  appearance  of  the  intestine  was  pre- 
cisely that  found  in  typhoid  fever,  and  there  was  no  indication  that 
the  ulceration  was  of  a  strumous  character. 


398 


CHAPTER    XIV. 

ON  COLIC. 

BY  the  term  colic  we  mean  a  severe  twisting  pain  in  the  abdomen, 
about  the  region  of  the  umbilicus,  without  inflammatory  action, 
generally  with  constipation,  but  sometimes  with  looseness  of  the 
bowels  and  vomiting.  Internal  strangulation  of  the  intestine  and 
intussusception  are  sometimes  considered  as  more  aggravated  and 
severe  forms  of  colic  on  account  of  the  pain  which  is  a  prominent 
symptom  in  many  cases;  but  the  former  may  be  in  its  early  stages 
altogether  free  from  pain,  until  distension  and  violent  peristaltic 
action  set  up  inflammation,  which  involves  all  the  coats  of  the  intes- 
tines; unless,  therefore,  we  consider  some  forms  of  colic  to  be  free 
from  pain,  in  some  of  its  stages,  we  cannot  regard  fatal  obstruction, 
arising  from  displacement  and  internal  strangulation,  as  a  form  of 
the  disease. 

Dr.  Copland  divides  colic  arising  from  functional  disorder  of  the 
bowels  into  four  classes: — 

1.  Flatulent,  nervous,  or  spasmodic  colic. 

2.  Colic  from  an  injurious  character  of  the  food. 

3.  Colic  from  morbid  secretion,  or  retained  excretions. 

4.  Colic  from  lead. 

This  division  appears  to  be  a  just  and  useful  one;  for  each  class 
indicates  widely  different  conditions,  which  require  different  treat- 
ment. 

In  flatulent  colic  the  intestines  become  distended  with  flatus; 
severe  twisting  pain  comes  on  round  the  region  of  the  umbilicus;  if 
the  pain  be  severe,  the  patient  becomes  cold,  and  a  clammy  sweat 
breaks  out;  the  pain  extends  to  the  back,  and  the  severity  of  the 
pain  is  relieved  by  a  change  in  its  position,  but  especially  by  eructa- 
tion, or  by  the  discharge  of  flatus  from  the  rectum;  during  the 
severity  of  the  pain,  the  pulse  becomes  depressed,  feeble,  and  ir- 
regular. 

In  nervous  and  spasmodic  colic  there  is  less  distension  of  the  abdo- 
men although  it  may  be  slightly  tympanitic;  the  pain  extends  to 
each  side  and  to  the  back,  and  is  sometimes  situat.d  across  the 
chest.  The  removal  of  pain  from  one  part  to  another,  and  especially 
the  discharge  of  flatus,  as  in  the  flatulent  colic,  afford  relief.  The 
abdomen  is,  however,  tolerant  of  pressure,  and  pain  is  occasionally 
relieved  by  this  means.  There  is,  also,  an  anxious  expression  of 
countenance,  with  coldness  and  clamminess  of  the  surface,  and  with 
depression  of  the  pulse,  if  the  pain  be  severe.  The  collapse  has  even 
been  mistaken  for  ruptured  intestine,  so  complete  may  be  the  pros- 
tration ;  in  colic,  however,  the  collapse  entirely  disappears  in  a  few 


ON  COLIC.  399 

hours;  in  perforation,  it  soon  terminates  in  death.  The  tongue  is 
not  generally  affected,  and  it  may  be  clean  or  furred;  the  evacuations 
from  the  bowels  also  may  be  as  in  health,  but  in  most  cases  they 
will  be  found  to  deviate  from  their  normal  condition.  In  the  nervous 
colic  of  hysteria,  the  urine  is  abundant  and  limpid.  In  the  spas- 
modic colic  of  gout  the  urine  contains  an  excess  of  lithic  acid,  and 
may  be  turbid  and  sca'nty. 

Causes. — Flatulent  colic  is  observed  in  nervous  and  hysterical 
subjects,  and' is  produced  by  the  rapid  evolution  of  gases  from  the 
contents  of  the  alimentary  canal,  whilst  in  some  cases  it  appears  to 
arise  from  change  in  the  secretions  of  the  mucous  membrane  itself. 
In  the  intemperate,  and  in  gouty  patients,  the  chylopoietic  viscera 
are  often  in  a  congested  and  morbidly  excited  state;  and  in  these 
cases  a  very  trifling  cause  will  produce  intense  colic. 

In  patients  reduced  by  exhausting  diseases,  by  loss  of  blood,  by 
the  too  long  continuance  of  farinaceous  and  fluid  aliments,. as  also 
by  over  lactation,  we  find  that  colic  of  this  kind  is  readily  induced. 

The  exciting  causes  are  alarm  and  fright,  exposure  to  cold  and 
wet,  especially  of  the  lower  extremities,  food  not  in  itself  indigestible, 
but  taken  when  the  powers  of  digestion  are  diminished,  either  from 
an  enfeebled  condition,  or  from  the  state  of  the  nervous  system. 

Diagnosis. — There  are  several  conditions  for  which  this  functional 
colic  may  be  mistaken,  and  which  are  important  to  remember. 

Perforation  of  intestine  is  generally  known  by  the  intensity  of  the 
collapse :  it  is  exceedingly  unusual  for  collapse  at  all  approaching  in 
severity  to  that  produced  by  ruptured  intestines  to  arise  from  func- 
tional colic,  although  it  is  sometimes  the  case.  During  the  passage 
of  a  calculus  from  the  gall-bladder  or  from  the  kidney,  intense  pain 
is  produced;  but  the  position  of  the  pain,  the  character  of  the  vomit- 
ing, and  in  the  latter  case,  the  pain  and  retraction  of  the  testicle, 
and  blood  in  the  urine,  enable  us  to  distinguish  these  diseases  from 
ordinary  colic. 

In  disease  of  the  spine,  severe  and  sometimes  intense  pain  is  pro- 
duced in  the  abdominal  parietes,  but  this  pain  has  generally  less  of 
the  twisting  pain  of  colic,  and  may  be  traced  in  the  course  of  the 
spinal  nerves;  sometimes,  however,  it  is  more  diffused  in  character, 
and  the  patient  can  scarcely  be  persuaded  that  the  cause  is  not  within 
the  abdomen. 

Aneurism  of  the  abdominal  vessels  and  abdominal  tumors  are 
sometimes  the  cause  of  intense  suffering,  but  the  character  of  the 
pain,  and  the  presence  of  a  tumor  with  other  signs  afford  easy  diag- 
nostic marks  of  their  true  character. 

In  peritonitis  there  is  exquisite  tenderness  of  the  abdomen,  whilst 
in  colic  the  pain  rarely  amounts  to  more  than  a  diffused  soreness,  and 
pressure  can  often  be  borne. 

In  tubercular  and  chronic  peritonitis  flatulent  distension  of  the 
abdomen  is  associated  with  soreness  or  tenderness,  less  severe  than 
in  ordinary  peritonitis ;  and  these  conditions  may,  in  the  early  stages, 
be  mistaken  for  simple  colic;  this  is  important,  because  by  an  over 
active  plan  of  treatment  disease  may  be  accelerated;  afterwards, 


400  ON    COLIC. 

\vhen  the  intestines  are  matted  together,  and  attacks  of  peritonitis 
are  set  up,  the  pain  and  tenderness  come  on  in  severe  paroxysms, 
when  they  are  less  likely  to  be  mistaken  for  simple  colic.  It  is  only 
in  the  early  conditions  of  this  disease,  and  especially  in  young  people 
of  nervous  and  excitable  temperament,  that  there  is  liability  to  such 
mistake. 

The  distinguishing  marks  between  colic  and  hernia  need  not  be 
dwelt  upon  ;  for  the  presence -of  an  external  tumor,  with  constipation 
and  stercoraceous  vomiting,  can  only  be  mistaken  for  simple  colic 
by  great  carelessness ;  and  in  every  case  of  colic,  even  before  severe 
vomiting  has  come  on,  it  is  well  always  to  examine  the  patient  for 
hernia.  In  intussuception  also,  intense  recurrent  pain  in  the  ab- 
domen of  a  twisting  character  is  sometimes  associated  with  diar- 
rhoea, and  I  remember  a  case  in  which  this  malady  was  mistaken 
for  colic  produced  by  irritating  substances ;  this  idea  was  strength- 
ened by  the  occurrence  of  the  attacks  of  pain  on  the  days  when  the 
patient  was  visited  by  his  friends.  Flatulent  distension  of  the 
stomach  is  sometimes  a  severe  and  even  fatal  disease,  but  the  dis- 
tension and  tympanitis  are  great,  and  the  form  of  the  abdomen  is 
characteristic.  The  intense  pain  arising  after  poisons,  as  from  mine- 
ral acids,  &c.,  is  associated  with  violent  vomiting ;  but  the  suffering- 
is  especially  experienced  in  the  mouth  and  gullet,  and  has  other 
symptoms  which  we  need  not  now  mention. 

Our  prognosis  in  flatulent  and  spasmodic  colic  is  generally  favora- 
ble, but  it  must  be  more  guarded  when  we  have  had  evidence  of 
previously  existing  disease,  or  where  the  collapse  is  great  in  a  patient 
who  has  been  affected  with  gout. 

Treatment. — The  ordinary  treatment  in  colic,  often  before  the 
patient  is  seen  by  a  practitioner,  is  to  administer  some  hot  brandy, 
and  water;  and  if  the  disease  be  of  the  simple  kind,  which  we  have 
described,  the  symptoms  may  be  thereby  relieved  ;  but  in  peritonitis, 
in  hernia,  in  perforated  intestine,  no  treatment  can  be  worse,  for  it 
takes  from  the  patient  the  chance  of  recovery.  Opium,  gr.  i-ij, 
and  laudanum,  are  the  most  useful  remedies  in  severe  functional 
colic,  and  may  be  given  either  alone  or  with  ether ;  chloroform  in 
doses  of  Rv  with  or  without  camphor,  chloric  ether  also,  and  the 
salts  of  morphia,  may  be  advantageously  administered.  Warmth 
should  be  applied  to  the  abdomen  by  means  of  hot  water,  hot  flan- 
nels, poppy  fomentation,  &c.,  and  sometimes  a  mustard  poultice  or  a 
hot  flannel  sprinkled  with  turpentine,  or  spongio-piline  previously 
wrung  out  of  hot  water  and  sprinkled  with  chloroform  and  bella- 
donna liniment,  mixed  in  equal  parts,  may  be  employed  to  relieve 
severe  pain. 

When  the  bowels  are  inactive,  and  when  no  indications  of  acute 
disease,  hernia,  or  internal  obstruction  exist,  a  warm  saline  purge 
may  be  given,  but  some  practitioners  prefer  a  dose  of  calomel,  with 
gr.  j  or  ij  of  opium,  or  colocynth  with  henbane,  or  castor  oil  with 
the  tinctures  of  rhubarb  and  opium.  Again,  enemata  are  sometimes 
of  much  service  in  emptying  the  colon,  and  thus  may  entirely  relieve 


ON    COLIC.  401 

the  disease ;  castor  oil  and  oil  of  turpentine,  colocynth  and  rue,  may 
each  be  employed  in  this  manner. 

If  the  attacks  be  less  severe,  but  repeated,  and  if  the  patient  be 
exhausted  and  anasmic,  steel  and  quinine  may  be  combined  with 
henbane  and  with  mild  aperients.  At  the  same  time  many  of  the 
vegetable  bitters — calumba,  cascarilla,  gentian — may  be  prescribed 
with  the  aromatic  spirit  of  ammonia,  with  henbane,  with  the  car- 
bonated alkalies  of  soda,  potash,  or  magnesia,  &c.  In  hysterical 
subjects  the  compound  assafoetida  pill  and  aloes,  musk,  or  myrrh 
may  be  used;  and  some  practitioners  employ  valerian,  castor,  sumbul, 
and  the  essential  oils,  to  relieve  the  painful  and  flatulent  distension 
of  the  abdomen. 

The  diet  should  be  of  a  form  easily  digestible,  but  sufficiently 
varied,  and  neither  bulky  nor  entirely  of  a  fluid  kind. 

When  a  gorged  state  of  the  portal  system  exists,  from  an  excess 
of  aliment  and  of  stimulants,  it  is  well  to  abstain  from  alcohol  in 
every  form;  but  this  abstinence  is  the  more  difficult  to  attain,  because 
the  colic  is  itself  often  relieved  by  fresh  doses  of  ardent  spirits.  So 
also  in  gout,  an  excess  of  animal  food  and  of  stimulants  aggravates 
the  disease,  but  the  patient  may  be  so  enfeebled  as  to  require  the 
continuance  of  stimulants  in  a  well  regulated  manner;  and  in  in- 
stances of  colic  with  exhaustion,  from  over  lactation,  loss  of  blood, 
great  mental  alarm,  &c.,  alcoholic  stimulants  are  of  great  value. 

2.  Colic  arising  from  the  injurious  character  of  th?  food.  This 
disease  has  many  symptoms  in  common  with  the  colic  just  described ; 
but  its  cause  is  different,  and  also  its  mode  of  relief. 

Severe  pain  comes  on  in  the  region  of  the  scrobiculus  cordis  and 
umbilicus,  sometimes  with  flatulent  distension,  two  or  three  hours 
after  eating.  Vomiting  occasionally  supervenes ;  and  it  may  be,  if 
the  food  is  of  an  injurious  character,  either  in  itself  or  from  the 
idiosyncracy  of  the  patient,  that  diarrhoea  is  set  up.  The  tongue 
is  whitish  and  furred,  or  enlarged,  and  red  papillae  are  observed 
through  the  fur,  or  it  is  injected  at  the  tip  and  edges.  The  pain  is 
followed  by  a  soreness  of  the  abdomen,  which  may  persist  for  several 
hours  or  days.  The  pulse  is  compressible,  and  the  respiration  is  less 
free  than  normal.  This  condition  may  pass  into  that  of  diarrhoea, 
or  of  enteritis;  or,  after  vomiting,  and  the  discharge  of  unhealthy 
evacuations  from  the  bowels,  the  patient  may  be  restored  to  health. 

This  form  of  colic  is  often  associated  with  disturbance  of  the 
cerebral  functions,  and  severe  pain  in  the  head,  dimness  of  sight, 
irritability  of  temper  come  on;  or  it  may  set  up  disturbance  of  the 
skin,  producing  urticaria  and  roseola,  and  in  children  of  strophulus 
and  other  lichenous  eruptions. 

If  the  injurious  diet  be  persisted  in,  the  colic  may  cease,  but  other 
conditions  consequent  on  general  impaired  nutrition  may  be  set  up. 

The  exciting  causes  are  salads,  cold  drinks,  acid  and  fermenting 
wines,  raw  fruit,  especially  stone  fruit,  mussels,  and  so-called  shell 
fish,  the  imperfect  mastication  of  food,  either  from  bad  teeth  or 
hurried  meals;  the  latter  cause  is  especially  found  m  those  who  are 
actively  engaged  in  business,  or  who  from  choice  or  necessity  posl 
26 


402  ON    COLIO. 

pone  the  meal  till  the  frame  is  almost  exhausted.  Severe  colic  of 
this  kind  is  sometimes  produced  by  mushrooms,  especially  where 
other  forms  than  the  edible  agaricus  are  taken,  and  dangerous  and 
alarming  symptoms  may  follow.1 

In  other  cases  the  diet  may  be  of  good  quality,  but  improperly 
administered ;  thus  the  most  severe  colic  may  be  produced  by  giving 
cold  milk  to  young  children.  Sudden  prostration  of  strength,  pain, 
a  sunken  eye,  vomiting,  and  afterwards  diarrhoea  are  produced,  and 
.the  motions  indicate  the  uudissolved  state  of  the  food  taken. 

In  the  diagnosis  of  these  cases,  equal  care  is  necessary  as  in  flatu- 
lent colic,  for  the  same  conditions  may  mislead  in  each ;  it  is  well 
also  to  remember  that  hernia,  perforation  of  the  intestine,  peritonitis, 
intussusception,  and  enteritis  may  produce  many  of  the  symptoms  of 
this  form  of  colic.  Ordinary  care  will  in  most  cases  enable  us  to 
detect  external  hernia;  the  pain  of  peritonitis  and  that  from  perfo- 
rated intestine  is  more  severe  in  kind,  and  different  in  character  from 
that  of  ordinary  colic.  Enteritis  and  intussusception  may  follow  as 
the  consequence  of  intestinal  irritation  of  the  kind  just  described, 
but  the  symptoms  of  these  are  of  greater  duration  than  those  of 
simple  colic;  and  when  due  to  the  administration  of  irritating 
poisons,  the  examination  of  the  vomited  matter  is  an  essential 
element  in  forming  a  correct  opinion  as  to  the  nature  of  the  case. 

Treatment. — If  vomiting  have  come  on,  and  irritating  matters 
have  already  been  freely  ejected,  the  symptoms  of  disease  often 
subside  spontaneously,  if  not  soothing  demulcents  may  be  given  ; 
but  if  pain  and  nausea  continue,  an  emetic  is  of  service.  Action 
from  the  bowels  should  be  insured  by  saline  aperient  medicines,  as 
the  carbonate  of  magnesia,  the  sulphate  of  potash,  the  tartrate  of 
soda,  or  by  a  free  mercurial  purge ;  and  demulcents,  as  arrowroot, 
milk,  rice,  mutton  or  veal  broth,  &c.,  should  constitute  the  only 
diet;  the  administration  of  saline  medicines,  with  antispasmodics, 
sedatives,  and  anodynes  may  be  necessary  for  a  short  time,  and  opium 
may  be  required  to  check  the  irritated  action  which  has  been  set  up, 
but  opium  should  not  be  given  whilst  irritating  substances  continue 
to  disturb  the  intestine. 

3.  Colic  from  retained  secretions  and  morbid  excretions. 

When  severe  pain  comes  on  with  diarrhoea  and  with  dark  bilious 
evacuations,  a  state  of  disease  is  produced  which  is  closely  allied  to 
the  bilious  diarrhoea  and  English  cholera,  which  we  have  previously 
noticed.  The  severe  pain  in  the  region  of  the  umbilicus  may  be 
associated  with  violent  vomiting  and  purging,  without  being  caused 
by  any  impropriety  of  diet.  The  patient  sometimes  becomes  pros- 
trate, the  motions  fluid,  the  surface  cold,  the  pulse  compressible,  and 
in  a  very  short  time  he  is  brought  to  extreme  collapse,  resembling 
Asiatic  cholera.  This,  in  its  most  severe  form,  constitutes  the 
English  cholera  that  is  found  to  prevail  each  autumn  in  our  own 
country.  But  there  are  less  degrees  of  this  condition  ;  the  vomiting, 
pain,  and  purging  may  be  more  moderate,  the  tongue  furred  and  in- 

1  Taylor  on  'Poisons.'     Christison  on  'Poisons.' 


Otf  COLIC.  403 

jected,  whilst  the  prostration  is  less.  Again,  in  other  instances, 
severe  pain  in  the  abdomen  of  the  character  of  colic  is  present,  with- 
out any  purging  or  vomiting,  but  with  a  sallow  complexion,  with 
furred  tongue,, pain  in  the  head,  oppression  of  the  mind,  and  impaired 
physical  energies. 

In  some  cases  the  prostration  is  so  severe  that  the  patient  suc- 
cumbs ;  but  more  generally,  I  may  say  in  most  cases,  the  symptoms 
subside,  and  are  followed  by  speedy  recoverv. 

Causes. — In  the  autumnal  season  there  is  much  greater  liability 
to  this  disease,  on  account  of  the  sudden  variations  in  temperature 
to  which  persons  are  often  exposed.  The  exhalations  from  decaying 
animal  and  vegetable  produce,  the  effluvia  from  drains,  also  induce 
this  form  of  colic.  In  miasmatic  districts,  and  in  damp  localities, 
there  is  still  fnore  liability  to  this  state,  and  so  great  may  be  the 
predisposition,  that  a  very  slight  excitement  is  sufficient  to  set  up 
the  disease. 

The  most  frequent  cause,  however,  is  disturbance  in  the  function 
of  the  liver,  whether  from  intemperance,  indiscretion  in  diet,  mental 
disquietude,  &c. ;  and  whatever  leads  to  congestion  of  the  portal 
system  tends  to  induce  colic  upon  slight  exciting  causes.  Attacks 
of  this  kind  are  often  designated  "  spasms." 

In  infants  it  is  exceedingly  common  to  have  colic  from  retained 
and  from  morbid  secretions;  pain  is  produced,  as  shown  by  the 
drawing  up  of  the  lower  extremities,  the  cry  is  almost  incessant, 
there  are  green  or  watery  evacuations,  containing  portions  of  coagu- 
lated milk  or  undigested  food,  the  countenance  is  anxious  and  dis- 
tressed, and  the  sleep  is  disturbed.  If  this  condition  continue,  it 
extends  so  as  to  affect  the  mucous  membrane  of  the  stomach,  and  is 
then  associated  with  violent  vomiting,  so  as  to  constitute  gastro- 
enteritis ;  rapid  prostration  may  ensue,  and  death  may  quickly 
follow,  or  more  slow  muco-enteritis  or  intussusception  may  super- 
vene ;  and  in  some  older  children  a  less  serious,  but  a  troublesome 
disease,  prolapsus  ani,  is  occasionally  produced. 

In  the  diagnosis,  the  remarks  made  in  reference  to  the  other 
descriptions  of  colic  are  equally  applicable ;  and  in  the  severer  forms 
the  disease  approaches  in  character  to  cholera. 

Our  prognosis  must  be  a  guarded  one,  for  although  most  cases 
recover,  still  in  some,  especially  in  infants,  an  untoward  result  follows, 
and  the  patient  becomes  perfectly  prostrate  and  dies. 

Treatment. — It  must  be  remembered  that  the  effect  of  the  vomiting 
and  purging  in  these  cases  is  to  remove  the  offending  matters  from 
the  alimentary  canal,  so  that  many  cases,  if  left  to  themselves, 
recover.  In  milder  cases  the  pain,  the  vomiting,  and  purging  are 
entirely  removed  by  the  administration  of  arrowroot,  or  by  the  in- 
jection into  the  rectum  of  thin  starch.  If  offending  substances  and 
secretions  are  retained,  castor  oil  with  tincture  of  rhubarb,  and  with 
opium,  afford  great  relief,  repeated  as  need  be;  and  it  is  in  this  con- 
dition, antecedent  to  the  aggravated  forms  of  Asiatic  cholera,  that 
we  may  expect  to  derive  benefit  from  the  plan  of  treatment  recom- 
mended by  Dr.  Johnson.  Some  administer  magnesia  with  good 


404  ON    COLIC. 

effect,  calcined  or  carbonate,  with  a  little  conium  or  henbane;  and 
gray  powder,  with  Dover's  powder,  or  calomel  with  opium,  may  be 
given  so  as  to  remove  the  abnormal  contents  of  the  intestine,  and  to 
check  the  pain  of  the  colic.  If,  however,  the  pain  and  diarrhoea 
continue,  it  is  well  to  give  absorbent  alkaline  medicines,  with  astrin- 
gents, as  chalk  with  catechu  and  opium,  or  kino,  krameria,  logwood, 
tormentilla,  &c.,  and  to  repeat  the  starch  injections,  or  injections  of 
oak  bark. 

In  the  subsequent  prostration,  mineral  acids,  the  sulphuric,  nitric, 
hydrochloric  acids,  with  vegetable  tonics,  are  of  great  service  in 
restoring  tone  to  the  mucous  membrane.  The  sulphuric  acid  lias 
been  much  used  in  this  form  of  diarrhoea,  and  we  have  already 
alluded  to  its  use.  The  secretions  from  the  mucous  membrane  of 
the  small  and  large  intestine  are  of  an  alkaline  character,  and  when 
the  membrane  is  irritated,  these  are  poured  out  in  greater  quantity, 
forming  an  unusually  thick  covering  to  the  membrane;  in  this  state 
the  mineral  acids  correct  the  secretions  by  their  astringent  effect  on 
the  capillaries,  checking  the  further  secretion  of  watery  mucus,  and 
they  assist  the  removal  of  that  already  formed.  The  solution  of 
potash,  and  the  alkalies  generally,  have  a  soothing  influence  upon 
the  mucous  membrane  of  the  alimentary  canal,  and  I  think  are  of 
greater  service  than  acids  in  the  early  stage  of  this  form  of  colic  and 
diarrhoea.  If  there  be  persistent  pain  warm  applications,  as  pre- 
viously described,  should  be  applied. 

Food  should  be  very  sparingly  administered,  and  only  of  the  most 
bland  form,  as  arrowroot,  rice,  tapioca,  veal  or  chicken  broth ;  if  the 
strength  fail,  we  must  add  brandy,  or  some  other  ardent  spirit. 

4.  Lead  colic. — Till  attention  was  drawn  to  the  subject  of  lead 
poisoning,  the  colic  arising  in  the  wine  and  cider  districts  was  attri- 
buted entirely  to  the  character  of  the  fluids  drunk;  this  is  still 
known  to  be  in  a  great  measure  the  case;  but,  since  the  observations 
of  Sir  George  Baker,  on  the  effects  of  poisoning  by  lead  in  its  several 
forms,  we  are  able  easily  to  distinguish  the  effects  of  lead  poisoning 
from  other  forms  of  colic. 

The  patient  exposed  to  the  influence  of  lead  becomes  of  a  sallow 
and  anaemic  aspect,  his  muscular  development  is  diminished,  and  his 
mental  capabilities  are  somewhat  enfeebled;  if  colic  come  on,  he 
experiences  severe  pain  in  the  abdomen,  at  first  moderate,  but  after- 
wards becoming  intense,  and  of  a  twisting  and  grinding  character 
about  the  umbilicus;  the  abdomen  is  contracted,  and  the  patient 
experiences  relief  by  firmly  compressing  the  abdomen  with  his 
hands,  or  even  across  a  chair;  the  bowels  are  obstinately  constipated, 
the  abdomen  is  neither  tender  nor  hot,  but  hard  and  contracted;  nor 
is  there  generally  any  vomiting,  but  the  patient  writhes  with  the 
severity  of  the  pain;  the  tongue  may  be  clean  or  furred,  the  pulse 
is  feeble,  but  not  increased  in  frequency,  and  the  urine  is  pale. 
After  some  hours  the  severity  of  the  pain  subsides,  but  it  may  again 
return  during  the  next  night,  or  after  taking  food.  The  severe  colic 
is  sometimes  accompanied  by  cerebral  disturbance,  but  this  is  a  rare 
occurrence,  although  severe  cephalalgia  or  epilepsy  may  precede  or 


ON  COLIC.  405 

follow  colic,  as  another  of  the  effects  of  lead  poisoning;  so  also 
paralysis  of  the  extensor  muscles  of  the  forearm  may  be  produced. 
The  colic  may,  also,  be  associated  with  severe  cramps  and  pains  in 
the  extremities;  the  constipation  sometimes  gives  place  to  diarrhoea, 
but  still  the  pain  continues,  or  rather  severe  soreness,  occasionally 
aggravated  into  intense  suffering.  On  examining  the  gums  we  find 
along  the  edge  a  deep  blue  dotted  line  composed  of  minute  particles 
of  sulphide  of  lead.  This  sulphide  is  formed  by  the  sulphuretted 
hydrogen  produced  by  decomposing  food,  lodged  "bet ween  the  teeth, 
reacting  on  the  lead  circulating  in  the  capillaries.  The  deposit  takes 
place  around  the  small  capillary  vessels  of  the  papillae  of  the  gum  as 
shown  by  Dr.  Fagge,  but  by  abrasion  it  becomes  exceedingly  super- 
ficial. This  line  is  a  very  distinctive  sign  of  lead  poisoning,  even 
when  the  abdominal  symptoms  are  insufficient  to  guide  us  tcTa  cor- 
rect diagnosis.  It  rarely  occurs  that,  colic  produced  by  lead  termi- 
nates fatally,  unless  associated  with  other  diseases.  In  a  case  pre- 
viously referred  to,  lead  colic  was  associated  with  chronic  ulceration 
of  the  stomach,  which  led  to  perforation  and  a  fatal  result.  We 
sometimes  find  that  paralysis  of  the  hands  or  wrists,  and  epilepsv 
are  coincident  with  the  colic;  it  is  unusual  to  have  paralysis  of  the 
ankles,  but  such  a  case  I  have  seen. 

The  proximate  cause  of  lead  colic  is  not  known,  whether  it  arises 
from  irregular  peristaltic  action  of  the  muscular  coat  of  the  intestine 
or  from  paralysis  of  one  part,  and  spasmodic  contraction  of  another. 
In  those  cases  which  I  have  examined,  and  in  others  recorded,  no 
abnormal  appearance  was  found  in  the  intestine.  The  manner  in 
which  the  lead  enters  the  system  is,  in  some  cases,  very  obscure,  but 
generally  it  is  sufficiently  manifest.  Drinking  fluids  from  leaden 
vessels  which  are  not  covered  with  any  protective  carbonate,  &c., 
and  acid  drinks  as  cider,  &c.,  from  leaden  vessels,  are  the  common 
modes  of  its  introduction ;  but  lead  colic  is  most  frequently  observed 
in  plumbers,  painters,  typefounders,  &c.,  men  who  are  constantly 
employed  in  handling  lead,  and  who  breathe  an  atmosphere  contami- 
nated with  minute  particles  of  it.  It  appears  probable  that  in  the 
mixture  and  using  of  paints  containing  lead  there  is  still  greater  lia- 
bility to  its  absorption ;  the  oil  contains  minute  particles  of  the  metal, 
and  its  ready  inhalation  is  effected.  In  many  instances  the  want  of 
proper  cleanliness  in  washing  the  hands  before  taking  food,  and  in 
changing  the  clothes,  very  much  aggravates  the  liability  to  poisoning 
by  lead.  It  is  sometimes,  however,  difficult  to  ascertain  how  the 
metal  has  entered  the  system.  Dr.  Addison  mentions  a  publican 
who  was  thus  poisoned  by  drinking  in  the  morning,  as  his  first 
draught,  the  ale  which  had  remained  in  the  leaden  pipe  during  the 
night.  Several  instances  have  been  know  where  lead  was  found  in 
the  snuff  which  the  patient  had  been  in  the  habit  of  taking.  It  has 
sometimes  been  produced  by  the  medicinal  use  of  acetate  of  lead; 
but  Dr.  Thompson  has  shown  that  there  is  less  liability  to  this  effect 
being  produced  when  the  lead  is  combined  with  opium,  or  given 
with  dilute  acetic  acid. 

The  diagnosis  of  lead  colic  is  sufficiently  clear  when  ordinary  cau- 


406  ON    COLIC. 

tion  is  used,  the  lead  line  along  the  gums,  with  pain  relieved  by 
pressure,  and  the  contracted  abdomen,  distinguish  the  disease ;  but, 
as  before  mentioned,  it  may  be  associated  with  chronic  ulcer  of  the 
stomach,  with  hernia,  &c.,  which  obscure  the  diagnosis,  and  may  lead 
to  a  fatal  result. 

In  uncomplicated  lead  colic  we  may  give,  especially  in  the  earlier 
attacks,  a  favorable  prognosis. 

Treatment. — The  indications  of  treatment  appear  to  be  sufficiently 
plain  in  this  disease — to  relieve  the  pain,  to  act  on  the  bowels,  and 
to  remove  lead  from  the  system.  For  the  relief  of  the  pain,  opium 
and  chloroform  are  the  best  remedies  and  may  be  administered  freely; 
to  act  on  the  bowels,  croton  oil  with  opium,  or  calomel  witli  opium, 
or  castor  oil  and  laudanum,  or  the  sulphate  of  magnesia  with  corn- 
pound  infusion  of  roses  and  henbane  may  be  used ;  or  we  may 
administer  injections  of  castor  oil  or  colocynth ;  warmth  should  be 
applied  at  the  same  time  to  the  abdomen. 

In  relation  to  the  subsequent  treatment,  we  should  not  be  content 
with  the  subsidence  of  the  colic  as  long  as  the  patient  retains  his 
sallow  and  anaemic  aspect,  and  has  a  lead  line  along  the  gums. 
Iodide  of  potassium  has  been  used,  and  it  has  been  found  that  the 
urine  contained  lead  during  its  administration ;  this  I  have  often 
attempted,  but  unsuccessfully,  to  verify.  Considerable  benefit  has 
been  found  in  dropped  hands  from  rubbing  iodine  ointment  into  the 
paralyzed  parts,1  and  still  more  by  the  use  of  electricity  and  galvan- 
ism locally  applied.  An  insulated  water  bath  has  been  recommended, 
the  patient  in  the  bath  being  connected  with  one  pole,  the  sides  of 
the  bath  with  the  other.  It  is  stated,  that  the  lead  is  removed  from 
the  body  of  the  patient,  and  deposited  upon  the  walls  of  the  bath ; 
but  I  have  not  seen  electricity  applied  in  this  manner ;  the  only 
opportunity  in  which  I  have  known  galvanism  used  in  colic,  to 
excite  the  bowels  to  action,  was  in  the  case  associated  with  gastric 
ulcer;  the  existence  of  the  gastric  ulcer  was  not  known,  and  fatal 
peritonitis  followed.  Warm  baths,  perfect  cleanliness,  bracing  air, 
and  preparations  of  steel,  after  the  removal  of  the  lead,  are  of  great 
service ;  but  a  considerable  time  is  required  for  the  system  to  become 
completely  free  from  the  poison. 

The  prophylactic  treatment  is  an  exceedingly  important  consider- 
ation to  those  employed  in  the  use  of  lead.  The  importance  of  per- 
fect cleanliness,  of  changing  the  clothes,  of  not  partaking  of  the 
meals  in  the  workshop  are  now  generally  acknowledged,  although 
they  are  not  acted  upon  as  their  cogency  demands. 

A  drink  containing  dilute  sulphuric  acid  with  lemon  juice  is  a 
useful  preventive  against  absorption  of  lead  for  those  who  are  ex- 
posed to  its  influence. 

1  'Medical  Times  and  Gazette,'  May,  1857. 


407  • 


CHAPTER   XY. 

ON  CONSTIPATION. 

WASTE  and  repair  are  necessarily  connected  with  the  performance 
of  every  function  of  the  human  body ;  and  the  various  excretory 
organs  are  the  channels  by  which  the  waste  materials  are  separated 
as  substances  no  longer  of  any  benefit,  and  the  retention  of  which 
becomes  increasingly  detrimental  to  the  whole  economy. 

The  large  intestine  may  be  looked  upon  as  an  important  excretory 
organ,  as  well  as  a  channel  for  the  separation  of  effete  material ;  and 
the  removal  of  its  contents  is  as  necessary  for  the  continuance  of 
human  life,  as  the  separation  of  carbonic  acid  from  the  lungs  in 
ordinary  respiration. 

The  colon  is  well  adapted  for  the  purpose  of  excretion,  and  by  its 
arrangement  serves  as  a  reservoir,  which  by  its  distension  permits 
of  an  occasional,  rather  than  a  continuous,  discharge  of  its  contents. 

But  in  this  periodical  movement  of  the  intestinal  canal  there  is 
great  difference  in  individuals ;  and  the  variation  within  the  bounds 
of  health  is  much  greater  than  is  usually  supposed  ;  with  some,  and 
perhaps  by  far  the  larger  number,  an  action  of  the  bowels  takes 
place  once  every  day,  or  it  may  be  two  or  three  times,  although 
either  condition  may  be  consistent  with  health ;  on  the  contrary, 
with  others,  it  may  be  that  an  action  every  second  or  third  day  is 
the  normal  condition ;  and  the  usual  period  may  be  even  extended 
to  every  fourth  or  seventh  day.  This  variation  must  be  borne  in 
mind,  otherwise,  in  the  attempt  to  produce  what  is  considered  bene- 
ficial, an  abnormal  condition  may  be  set  up,  and  comfort  and  health 
lost  in  striving  to  bind  all  to  the  same  universal  law. 

Much,  however,  may  be  acquired  by  habit;  regularity  maybe 
attained ;  or  inattention  and  want  of  care  may  induce  a  condition 
which  will  almost  baffle  any  subsequent  effort  to  remedy.  Pre- 
mising that  the  healthy  action  in  one  may  be  disease  in  another,  we 
may  define  constipation  to  be  a  less  frequent  action  of  the  bowels 
than  is  the  healthy  condition  of  each  individual.  Ordinary  consti- 
pation arises  from  "the  insufficient  contraction  of  the  muscular  coat 
of  the  intestine ;  the  canal  becomes  more  and  more  distended,  and 
with  each  increase  in  the  circumference  of  the  tube  greater  power  is 
required  to  force  onward  its  contents.  I  have  sometimes  observed 
a  colon  so  enlarged  in  obstinate  constipation  by  distension  and  con- 
sequent loss  of  power,  that  it  has  measured  as  much  as  twelve  to 
fifteen  inches  in  circumference ;  the  power  which  must  have  been 
necessary  to  propel  the  contents  must  have  been  enormous.  And  it 
appears  probable  that  in  this  extreme  distension,  a  state  closely  allied 
to  paralysis  of  the  muscular  parietes  is  the  result ;  sometimes,  how- 


408  ON    CONSTIPATION. 

ever,  this  gradual  distension  is  the  effect,  rather  than  the  cause  of 
paralysis. 

A  second  effect  of  constipation  is  that  the  lateral  pouches  of  the 
colon  formed  by  the  circular  and  longitudinal  bands  of  muscular 
fibre,  become  more  and  more  distended,  and  being  thus  filled  out, 
their  contents  are  removed  from  the  central  current,  and  become 
impacted,  while  the  bowels  act  with  some  degree  of  regularity  ;  these 
impacted  feces  may  frequently  be  felt  as  tumors  through  the  abdomi- 
nal walls,  alarming  the  patient,  but  disappearing  under  judicious 
treatment. 

Pouches  of  the  colon  sometimes  become  of  considerable  size,  and 
are  generally  surrounded  by  the  circular  fibres  of  the  canal ;  but  not 
^infrequently  these  fibres  yield,  and  the  mucous  layer  projects, 
covered  only  by  the  peritoneum,  thus  forming  a  mere  elongated  sac, 
filled  with  mucus,  or  more  frequently  with  feces.  The  orifices  of 
these  small  sacs  are  surrounded  by  the  hypertrophied  circular  and 
longitudinal  fibres,  and  their  contents  remain  almost  shut  off'  from 
the  intestinal  canal.  These  pouches  are  the  result  of  constipation, 
the  muscular  fibres  become  hypertrophied,  and  their  efforts  to  propel 
onward  the  contents  of  the  canal  lead  to  these  hernial  protrusions. 

I  have  most  frequently  observed  pouches  in  connection  with  the 
sigmoid  flexure ;  but  they,  probably,  occur  at  any  part  where  the 
longitudinal  fibres  form  a  triple  band  rather  than  an  uniform  layer. 
In  one  case  they  were  situated  about  every  half  inch,  forming  a 
double  row  on  each  side  of  the  colon.  No  muscular  fibres  could  be 
detected  in  several  of  them,  beyond  the  immediate  vicinity  of  the 
mouth  of  the  sac ;  they  consist  merely  of  mucous  membrane,  sub- 
mucotis  tissue,  with  fat  and  peritoneum.  They  have  latterly  been 
observed  in  the  smaller  intestine  where  they  usually  occur  at  the 
mesenteric  attachment  of  the  bowel.  These  pouches  do  not  appear 
to  produce  any  symptom,  nor  do  they  lead  to  dangerous  results.  A 
remarkable  case  of  this  kind  I  observed  in  a  patient,  aged  sixty-two, 
who  died  from  cancerous  disease  of  the  liver  and  lungs,  with  bron- 
chitis and  emphysema.  The  sigmoid  flexure  and  rectum  were  con- 
tracted, and  presented  numerous  pouches,  some  of  which  were  half 
an  inch  in  length  ;  they  were  arranged  in  two  rows  about  one  inch 
apart;  these  pouches  consisted  of  mucous  membrane  and  perito- 
neum; the  circular  muscular  fibres  were  placed  between  them,  and 
the  longitudinal  fibres  on  either  side,  and  both  of  these  fibres  were 
hypertrophied.  The  pouches  were  filled  with  mucus  and  feces.  There 
was  neither  ulceration  nor  evidence  of  cicatrix,  but  it  appeared  that 
the  constipated  bowels,  to  which  the  patient  had  been  subject,  had 
led  to  unequal  pressure  and  saccular  distension,  or  hernioe  of  the 
mucous  membrane.  Appearances  of  this  kind,  though  in  less  degree, 
are  by  no  means  uncommon  in  the  colon,  especially  towards  its 
termination. 

Continued  distension  of  the  colon  with  solid  contents  alters  its 
position ;  this  is  especially  observed  in  the  transverse  colon,  and  in 
the  sigmoid  flexure ;  the  convexity  of  the  former  becomes  greatly 
increased,  and  the  double  curve  of  the  latter  is  rendered  more  evi- 


ON    CONSTIPATION.  409 

dent.  The  attachment  of  the  great  omentum,  and  the  ready  separa- 
bility of  its  layers,  appear  to  be  especially  designed  to  allow  of  free 
distension  of  the  transverse  colon,  but  a  continued  pressure  increases 
the  curve,  till  at  last  it  may  form  a  large  sigmoid  flexure,  reachino- 
nearly  to  the  brim  of  the  pelvis.  Increased  curvature  of  the  trans- 
verse colon  is  of  common  occurrence,  but  sometimes  its  malposition 
seems  to  be  congenital;  thus  \ve  have  seen  the  descending  colon 
passing  downwards  in  close  contact  with  the  ascending,  and  then 
terminating  in  a  transverse  colon,  which  was  situated  at  the  brim  of 
the  pelvis,  thus  connecting  the  descending  colon  with  the  si°rnoid 
flexure. 

The  most  important  result  arising  from  continued  constipation  is 
the  retention  within  the  blood,  or  the  reabsorption  into  it  of  mate- 
rials which  are  essentially  excrementitious.  The  excrementitious 
portion  of  the  bile  is  not  removed,  and  the  functions  of  the  liver  are 
imperfectly  performed;  the  blood  of  the  whole  portal  system  is 
rendered  more  or  less  impure;  the  complexion  becomes  changed, 
sallow  and  muddy;  the  brain  does  not  act  with  its  wonted  energy, 
and  there  is  a  manifest  diminution  in  the  elasticity  of  both  the  mind 
and  bodv. 

The  functions  of  other  viscera  become  disordered,  and  the  en- 
larged and  distended  colon  interferes  mechanically  with  the  healthy 
action  of  adjoining  viscera.  The  caecum  and  ascending  colon  may 
press  injuriously  upon  the  ilio-hypogastric  and  genito-crural  nerves, 
leading  to  severe  neuralgic  pain  over  the  crest  of  the  ilium  or  groin; 
and  pain  of  this  kind  may  be  mistaken  for  rheumatism,  lumbago, 
and  sciatica,  whilst  it  entirely  disappears  when  mechanical  pressure 
on  the  nerves  has  been  removed.  This  pressure  is,  however,  more, 
frequently  exerted  on  the  left  side  by  the  sigmoid  flexure  than  by 
the  ciecum  on  the  right;  the  veins  of  the  lower  extremity  and  the 
testicle  or  ovary  may  become  pressed  upon,  and  oedema  of  the  feet 
and  varicose  veins  result;  by  the  distended  transverse  colon  the 
stomach  is  interfered  with,  and  its  movements  are  to  a  certain  ex- 
tent crippled. 

In  reference  to  the  causes  of  constipation,  the  first  to  be  mentioned 
is  original  peculiarity  of  habit,  or  idiosyncrasy;  that  such  peculiarity 
does  exist  cannot,  I  think,  be  doubted,  although  it  must  not  be  con- 
sidered as  disease  in  the  same  light  as  constipation  arising  from 
organic  change. 

A  second  cause  is  an  abnormal  condition  of  the  abdominal  walls. 
The  contraction  of  the  parietal  muscles  is  an  important  aid  in  defe- 
cation, and  their  tonic  contraction  assists  the  peristaltic  action  of  the 
intestines.  The  constipated  condition  of  the  bowels  in  diseased  and 
fractured  spine  may  be  explained  in  part  by  this  cause,  namely, 
paralysis  of  the  parietal  muscles.  Diminution  of  contractile  power 
also  arises  from  degeneration  of  the  muscles  themselves,  and  from 
excessive  development  of  fat;  and  sometimes  the  contraction  of  these 
muscles  is  checked  by  pain,  either  of  a  neuralgic  character,  or  from 
local  inflammation,  as  boils,  fascial  abscess,  carbuncle,  &c.  Inactivity, 
or  sedentary  life,  tends  to  produce  constipation  in  the  same  manner. 


410  ON    CONSTIPATION. 

How  different  the  condition,  when  many  hours  are  spent  day  after 
day  in  nearly  the  same  position,  from  that  of  active  muscular  exer- 
tion? Contrast  the  mechanic,  where  the  whole  frame  is  in  constant 
movement,  with  the  overworked  sempstress;  the  clerk,  sitting  for 
hours  over  the  desk,  with  one  engaged  in  active  out-door  occupation; 
the  professional  or  literary  man,  almost  deprived  of  walking  exercise, 
to  another  in  the  full  enjoyment  of  it.  The  muscular  exertion  of 
walking,  horse-riding,  various  athletic  exercises,  or  other  means  by 
which  the  muscles  of  the  abdominal  walls  are  brought  into  play,  are 
thus  essentially  necessary  for  maintaining  good  health. 

A  third  cause  of  constipation  arises  from  the  alteration  of  the 
secretions  poured  into  the  large  intestine.  These  secretions,  or  rather 
excretions,  arise  from  the  mucous  membrane  of  the  large  intestine 
itself,  from  the  small  intestine,  from  the  liver,  and  from  the  pancreas, 
and  they  undergo  various  changes;  thus  a  congested  condition  of 
the  liver  and  of  the  portal  system  of  veins,  induces  modification  of 
the  whole  chylopoietic  viscera,  for  the  vena  portas  receives  its 
branches  from  the  large  and  small  intestines,  stomach,  &c. ;  hence 
also  a  state  of  congestion  of  the  liver  not  only  checks  the  formation 
of  bile,  but  it  interferes  with  normal  secretions  from  other  parts, 
often  diminishing  them  in  quantity,  and  altering  them  in  quality; 
in  this  manner  we  have  constipation  from  hepatic  disturbance,  and 
from  the  intemperate  use  of  alcoholic  liquors;  thus  also  in  jaundice, 
constipation  is  generally  the  result,  the  motions  become  clayey,  white, 
and  exceedingly  offensive. 

Diseases  of  the  lungs  and  heart,  which  interfere  with  the  free 
circulation  of  the  blood,  render  the  right  side  of  the  heart  engorged ; 
and  as  a  necessary  consequence  of  this  distension,  the  liver  and  the 
whole  portal  system  are  congested,  the  secretion  from  the  mucous 
membrane  becomes  scanty,  and  constipation  is  the  result.  This 
constipation  increases  the  original  disease  of  the  heart,  and  the 
remark  is  often  made  by  those  who  are  the  subjects  of  chronic  dis- 
ease of  the  lungs  and  heart,  as  chronic  bronchitis,  emphysema, 
asthma,  and  valvular  disease  of  the  heart,  that  as  soon  as  the  bowels 
become  confined,  they  experience  increased  discomfort. 

A  state  which  may  be  called  chronic  catarrh  of  the  mucous  mem- 
brane is  sometimes  induced  from  this  congestion  of  the  portal  system 
and  constipation  very  frequently  follows ;  but  another  cause  of  this 
altered  secretion  arises  almost  from  an  opposite  cause,  namely,  a  di- 
minished supply  of  blood  to  the  mucous  membrane.  The  secretion 
is  scanty,  but  from  a  different  reason ;  in  the  former  case,  secretion 
is  checked  by  engorgement  of  the  vessels  with  blood ;  in  the  latter, 
by  a  diminished  supply. 

The  various  excretory  organs  are  closely  connected  the  one  with 
the  other.  The  excretions  from  the  lungs,  the  skin,  the  kidneys,  the 
alimentary  canal,  are  intimately  associated.  Their  nicely  adjusted 
balance  continues  during  health,  but  if  one  becomes  greatly  in  excess 
the  others  consequently,  and  almost  in  that  proportion,  suffer;  thus 
excessive  secretion  from  the  skin  diminishes  secretion  from  other 
parts.  The  box  of  rhubarb  pills  is  often  carried  by  the  pedestrian 


ON    CONSTIPATION.  4H 

—and  why  ?  The  muscular  exercise  and  action  of  the  abdominal 
muscles  should  induce  increased  action;  and  such  would  in  many 
cases  happen  if  the  exercise  were  moderate  ;  but  if  persisted  in  so  as 
to  induce  free  perspiration,  with  rapid  molecular  changes  in  the  mus- 
cles, blood  is  actually  withdrawn  from  the  alimentary  canal  to  the 
skin  and  muscles;  the  internal  secretions  become  diminished,  and 
constipation  results.  A  similar  condition  is  observed  when  exces- 
sive action  of  the  kidneys  carries  off  the  aqueous  portion  of  the  blood 
too  freely.  The  kidneys  act  less  when  the  skin  energetically  per- 
forms its  function  ;  and  on  the  contrary,  when  the  warm  air  of  sum- 
mer is  suddenly  changed  to  a  cold,  chilly  temperature,  the  action  of 
the  skin  is  checked,  and  increased  renal  secretion  is  induced.  We 
have  already  alluded  to  this  in  our  remarks  on  diarrhoea  and  dysen- 
tery ;  for  the  sudden  interference  with  the  action  of  the  skin  often 
induces  those  diseases;  hence  autumnal  diarrhoea,  and  the  severe 
dysenteries  of  hot  climates.  Cerebral  congestion,  over-anxiety  of 
mind,  extreme  mental  occupation,  act  also  in  this  manner,  as  well  as 
more  directly  upon  the  nervous  condition  of  the  alimentary  canal. 
There  is  increased  circulation  of  blood  in  the  brain,  and  less  in  the 
abdomen ;  for  great  excitement  of  the  cerebrum  is  associated  with 
diminished  activity  in  the  nerve  of  organic  life. 

Constipation  is  also  induced  by  general  anaemia,  and  loss  of  blood; 
and  very  frequently  in  spanasmia  or  poverty  of  blood,  as  in  the  chlo- 
rosis of  young  women.  The  condition  of  the  blood  is  here  the  pri- 
mary cause  of  other  secondary  changes.  There  is  inactivity  or 
irregular  muscular  exertion,  and  the  secretions  are  imperfect  both  in 
their  character  and  quantity. 

A  fourth  cause  of  constipation  is  a  diseased  state  of  the  coats  of 
the  intestine  itself.  I  have  already  alluded  to  the  secretion  from  the 
mucous  membrane,  and  especially  refer  here  to  the  condition  of 
the  muscular  layer,  and  to  the  nervous  supply  of  the  alimentary 
canal. 

The  muscular  layer,  in  a  state  of  health,  contracts  from  slight  di- 
rect stimulus  upon  the  contents  of  the  canal,  but  this  contractile 
power  is  liable  to  various  modifications ;  sometimes  it  is  excessive, 
leading  to  the  immediate  expulsion  of  the  contents,  but  more  fre- 
quently it  is  deficient,  leading  to  constipation.  This  inactivity 'may 
arise  from  the  muscular  coat  having  been  unwisely  excited  to  action 
by  improper  means — as  by  the  injudicious  use  of  purgatives,  either 
from  their  habitual  continuance  or  from  their  powerful  character; 
and  the  muscular  coat  is  left  in  such  a  state  that  it  will  not  contract 
from  the  normal  stimulus,  whilst  the  diminution  of  contractile  power 
is  increased  by  the  constipation  with  which  it  is  associated.  The  in- 
testine becomes  distended,  the  calibre  increases,  and  the  muscular 
fibre,  which  could  easily  propel  the  contents  of  a  cylinder  one  to  two 
inches  in  diameter,  is  unable  to  do  so  when  the  cylinder  is  increased 
to  three  or  four  inches  in  diameter,  and  the  canal  many  times  its 
normal  size.  A  state  of  actual  paralysis  of  the  muscular  fibre  of  the 
intestine  may  be  thus  induced,  in  the  same  manner  as  the  urinary 
bladder,  when  enormously  distended,  is  unable  to  expel  its  contents . 


412  ON    CONSTIPATION. 

Repeated  doses  of  blue  pill  and  black  draught,  of  violent  purgative 
medicines,  of  mercurials,  &c.,  render  the  whole  coat  of  the  intestine 
ina  relaxed  and  enfeebled  condition ;  the  mucous  membrane  is  debili- 
tated, the  muscular  fibre  is  inactive,  and  partially  paralyzed.  I  do 
not  mean  for  a  moment,  that  such  remedies  are  not  frequently  at- 
tended with  marked  relief  to  existing  morbid  conditions;  but,  the 
continued  use  of  them  leads  to  chronic  disease,  which  is  perpetuated 
as  well  as  induced  by  the  remedy  itself,  although  in  some  cases  this 
is  borne  with  apparent  impunity. 

Dr.  Billing  related  to  me  an  instance  of  a  lady,  who  for  thirty 
years  took  a  grain  of  calomel  every  night;  and  a  colleague  of  his 
own  at  the  London  Hospital  for  more  than  thirty  years  had  taken 
the  same  quantity  daily  after  dinner. 

It  is,  I  believe,  universally  acknowledged  that  the  long-continued 
habit  of  taking  snuff  irritates  the  fauces  and  epiglottis,  producing 
cough,  &c.  Nor  is  dyspepsia  the  only  further  ill  effect  of  this  habit; 
the  irritating  particles  extend  along  the  whole  length  of  the  alimen- 
tary canal.  Several  inveterate  snuff-takers  have  complained  to  me 
of  the  irritable  state  of  the  bowels;  and  it  appeared  that  the  mucous 
membrane  was  unnaturally  stimulated  and  irritable.  The  oft-re- 
peated stimulus  leads  to  an  enfeebled  condition  of  the  mucous  mem- 
brane, to  a  loss  of  contractile  power,  as  well  as  of  healthy  secretion 
and  of  nervous  stimulus;  as  regards  the  stomach,  dyspepsia  is  the 
result;  in  the  intestine,  it  leads  to  diarrhoaa  or  constipation;  in  some 
cases  the  rectum  is  principally  affected,  and  either  the  feces  are 
retained  so  as  to  form  an  impacted  mass,  which  the  bowel  is  unable 
to  propel;  or,  if  the  excreta  be  fluid,  the  same  weakness  allows  the 
contents  to  pass  rapidly  to  the  sphincter,  which  is  itself  so  enfeebled 
as  to  be  unable  to  restrain  an  involuntary  discharge.  Snuff  may 
actually  be  seen  among  these  excreta. 

Drinking  excessively  of  cold  water  induces  an  enfeebled,  relaxed 
condition  of  the  mucous  membrane  of  the  alimentary  canal. 

Cicatrices  of  the  mucous  membrane  after  ulceration,  as  in  dysen- 
tery, lead  to  contraction  and  diminution  of  the  canal;  they  cause 
mechanical  obstruction,  and  interfere  with  regular  peristaltic  action. 
Tumors,  or  any  growths  pressing  upon  either  small  or  large  intes- 
tine, may  induce  constipation  in  a  similar  manner;  but  we  defer 
entering  into  the  causes  of  insuperable  constipation,  arising  from  cica- 
trices, till  we  speak  of  ileus.  With  these  cases  also  we  shall  consider 
other  more  serious  causes  of  constipation,  namely,  cancerous  and 
fibroid  growths,  tumors  connected  with  the  intestine,  or  pressing 
upon  it,  and  the  various  forms  of  internal  strangulation  and  intus- 
susception, &c. 

In  speaking  of  constipation  arising  from  diminished  secretion,  we 
have  alluded  to  cerebral  disease,  and  cerebral  congestion,  from  over 
anxiety  and  mental  work.  Various  causes  often  co-operate  in  these 
instances;  a  sedentary  life  and  diminished  muscular  exertion,  are 
associated  with  changes  in  the  secretions  and  with  diminution  of 
contractile  power  of  the  intestine.  In  many  diseases  of  the  brain, 


ON    CONSTIPATION.  413 

the  abdomen  becomes  collapsed,  as  if  the  healthy  tone  of  the  parts 
was  lost. 

In  diseases  or  injuries  of  the  spinal  cord,  this  relation  between  the 
nervous  system  and  the  alimentary  canal  is  still  more  evident;  the 
bowels  are  constipated,  and  action  is  often  induced  with  difficulty; 
not  only  from  paralysis  of  the  parietal  muscles,  but  from  diminution 
of  the  contractile  power  of  the  intestinal  muscular  layer,  as  well  as 
from  change  in  the  secretions  of  the  mucous  membrane.  The  paraly- 
sis is  painfully  shown  in  these  cases  by  the  want  of  control  over  the 
sphincter  muscle;  for  the  motions  escape  involuntarily. 

In  advanced  life  the  feeble  contraction  of  the  parietes,  the  dimin- 
ished excitability  of  the  intestinal  muscular  coat,  and  the  necessarily 
less  active  life,  often  produce  constipation,  which  is  increased  by  the 
nervous  alarm  of  the  patient  at  the  non-action  of  the  bowels. 

Constipation  is  also  a  sign  of  inflammation  of  the  peritoneal  in- 
vestment of  the  intestines;  the  muscular  coat  becomes  involved,  and 
ceases  to  contract  with  energy.  This  is  a  wise  and  beneficent  pro- 
vision, to  which  we  have  already  referred. 

Constipation  also  is  induced  when  defecation  is  painful,  as  in  in- 
flamed haemorrhoids,  in  ulceration  of  the  rectum,  and  in  diseases  of 
adjoining  parts.  So  severe  is  the  pain  in  some  cases,  that  action  of 
the  bowels  is  prevented  by  the  sufferer,  who  is  unwilling  to  undergo, 
or  rather  is  desirous  to  postpone  to  the  latest  period,  that  which 
produces  such  intense  suffering.  It  is  a  merciful  provision  that  in 
health  such  necessary  actions  are  free  from  pain. 

It  sometimes  happens  that  a  spasmodic  constriction  of  the  alimen- 
tary canal,  especially  the  rectum,  induces  constipation ;  in  most 
cases,  however,  it  will  be  found  that  there  is  associated  with  this 
spasmodic  contraction  some  direct  cause  of  irritation  at  the  part,  as 
a  minute  fissure  or  ulceration  of  the  mucous  membrane,  disease  of 
the  bladder  or  uterus,  &c. 

A.  fifth  cause  of  constipation  may  be  the  state  of  the  contents  of  the 
large  intestine.  The  feces  having  become  hard  and  impacted,  remain 
like  a  foreign  body,  and  are  only  removed  with  considerable  diffi- 
culty. The  character  of  the  food  may  have  been  such  as  to  induce 
this  impaction ;  for  many  cases  are  recorded  of  substances  which 
have  been  taken  habitually,  as  brown  coarse  bread,  leaving  the  un- 
digested parts  to  become  agglutinated  ;  so  also  with  calcined  magne- 
sia, taken  medicinally  day  after  day;  undigested  meat,  ligamentous 
tissues,  arteries,  fish  bones,  human  hair,  may  form  these  concrete 
masses ;  and  amongst  lunatics  stones  and  pebbles  which  have  been 
s\vallowel  may  thus  become  impacted. 

It  is  in  the  lower  part  of  the  large  intestines  that  feces  generally 
become  thus  hardened  ;  although  it  sometimes  takes  place  to  a  less 
degree  in  the  caecum,  and  in  the  ascending  and  transverse  colon. 

Sixthly. — Mechanical  obstructions  have  been  cursorily  alluded  to 
in  reference  to  tumors,  as  affecting  the  coats  of  the  intestine ;  and  it 
is  of  very  common  occurrence  in  pregnancy  and  ovarian  growths, 
to  find  that  direct  pressure  is  exerted  upon  one  or  other  part  of 


414  ON    CONSTIPATION. 

the  colon,  so  as  to  interfere  with  regular  and  free  action  of  the 
bowels. 

Symptoms. — Constipation  manifests  its  effects  on  the  brain  by  in- 
ducing torpor  of  the  mind  with  diminished  energy  and  activity  ;  the 
sleep  is  disturbed,  and  not  refreshing,  the  mind  easily  agitated,  and 
often  melancholic.  There  is  also  a  general  malaise,  which  renders 
the  patient  unwilling  to  undergo  ordinary  exertion  and  fatigue ; 
pain  in  the  head,  sometimes  at  the  forehead,  at  other  times  in  the 
occipital  region,  is  often  present;  and  when  diseased  arteries  of  the 
brain,  or  other  predisposing  causes  of  disturbed  cerebral  circulation 
exist  there  is  not  unfrequently  vertigo,  with  disturbed  vision,  hazi- 
ness, sparks  before  the  eyes,  muscae  volitantes,  ringing  noise  in  the 
ears  (tinnitus  aurium);  and  occasionally  there  is  momentary  loss  of 
consciousness. 

When  disease  of  the  heart  exists  marked  symptoms  of  disturbance 
in  the  circulatory  organs  are  sometimes  produced  ;  the  most  frequent, 
perhaps,  is  irregularity  of  the  pulse,  and  uncomfortable  palpitation 
of  the  heart ;  and  the  pulse  is  generally  compressible.  As  to  the 
respiratory  organs,  dyspnoea  is  not  unfrequently  induced  by  the  im- 
pediment to  free  action  of  the  diaphragm.  Pain,  especially  across 
the  sternum,  is  often  ascribed  to  the  chest,  whilst  it  really  arises  from 
distended  colon. 

The  abdomen  is  full,  and  sometimes  masses  of  a  round  and  hard 
character  can  be  felt  in  the  course  of  the  colon,  simulating  morbid 
growths,  which  when  perceived,  cause  alarm  to  the  patient;  this 
state  of  partial  impaction  may  exist,  although  there  is  daily  action 
from  the  bowels,  a  central  channel  being  left,  or  fluid  feces  pass 
around  the  obstruction  ;  the  tongue  is  flaccid  and  indented  by  the 
teeth,  showing  an  atonic  state  of  the  muscular  fibre. 

Various  neuralgic  pains  are  often  induced,  from  direct  pressure 
upon  the  nerves,  sometimes  in  the  right  hypochondriac  regions; 
frequently  over  the  crest  of  the  ileum  in  the  course  of  the  ilio-hypo- 
gastric  nerve,  and  in  the  course  of  the  genito-crural,  to  the  groin  and 
the  testicle. 

Aching  pain  in  the  loins  and  in  the  lower  extremities  arises  from 
interference  with  the  free  return  of  blood  ;  and  beside  this  symptom, 
a  varicose  condition  of  the  veins  is  induced  or  aggravated ;  and  con- 
sequent oedema  is  produced.  A  similar  condition  of  the  hernor- 
rhoidal  veins  is  also  the  result  of  habitual  constipation  ;  and  all  the 
discomfort  attendant  on  hemorrhoids  follows.  Irritation  of  the 
adjoining  pelvic  organs  is  sometimes  excited,  as  irritability  of  the 
bladder. 

It  has  been  stated,  that  a  distended  transverse  colon  may  exert 
pressure  on  the  duodenum,  so  as  to  lead  to  symptoms  of  dyspepsia; 
such  an  effect  is  exceedingly  doubtful,  but  when  adhesions  have 
taken  place  between  the  first  portion  of  the  duodenum  and  the  colon, 
great  distension  of  the  latter  then  exerts  pressure ;  generally,  how- 
ever, these  symptoms  are  due  to  the  imperfect  separation  of  execreta, 
and  to  congestion  of  the  portal  system.  - 

Diagnosis. — The  diagnosis  of  constipation  may  be  considered  as 


ON    CONSTIPATION.  415 

generally  sufficiently  clear,  but  the  various  secondary  symptoms 
may  lead  to  serious  misapprehensions.  As  to  impacted  feces  in  the 
course  of  the  colon,  they  have  very  often  been  mistaken  for  tumors; 
but  their  local  character,  mobility,  and  general  symptoms  serve  to 
distinguish  them.  This  discrimination  is  more  easy  in  the  ascending 
or  transverse  colon;  but  in  the  descending  colon,  and  especially  in 
the  sigmoid  flexure,  the  diagnosis  is  more  difficult.  Cancerous  ob- 
struction at  the  sigmoid  flexure  is  very  insidious,  and  gradual  consti- 
pation is  its  principal  symptom ;  but  local  pain,  and  a  small,  firm, 
hard  tumor  at  that  part  are  very  diagnostic  of  an  obstruction  of  this 
kind.  Impacted  feces,  however,  in  the  rectum  and  sigmoid  flexure, 
sometimes  become  so  firm  and  immovable,  that  the  symptoms  mav 
closely  resemble  organic  disease;  weeks  may  be  passed  without,  an 
evacuation,  and  gradually  severe  symptoms  result,  as  vomiting,  and 
occasionally  extreme  pain.  A  careful  examination  will,  in  most 
cases,  render  the  diagnosis  easy,  and  the  patient  perseverance  in 
injections  and  mild  aperient  remedies  will  be  effective ;  we  do  not 
find  in  simple  impaction  of  feces  that  the  stomach  becomes  so  irri- 
table as  in  organic  strangulation.  A  hardened  mass  in  the  rectum 
produces  the  repeated  discharge  of  fluid  feces  or  of  a  clear  mucus, 
which  is  often  mistaken  for  diarrhoea;  and  whenever  these  symptoms 
occur,  it  is  most  important  to  make  a  digital  examination. 

A  case  is  recorded  by  Mr.  Staniland,1  of  a  patient,  aet.  73,  who  had 
habitual  constipation,  so  that,  during  the  last  five  years  of  her  life 
the  bowels  were  only  acted  upon  once  in  every  two  months;  after 
being  confined  for  four  months  and  eight  days  they  were  very  freelv 
acted  upon;  seven  months  then  elapsed  without  any  pain  or  evacu- 
ation. Some  weeks  before  death  she  had  a  fall,  which  produced 
very  severe  pain  in  the  region  of  the  caecum,  and  led  to  local  inflam- 
mation, gangrene,  and  fecal  extravasation  into  the  peritoneum.  The 
intestines  were  found  enormously  distended  with  feces,  the  transverse 
colon  was  nine  inches  in  diameter,  and  the  sigmoid  flexure  ten  and 
a  half;  the  rectum  six  inches.  A  remarkable  instance  of  constipa- 
tion of  nearly  four  months'  duration,  after  fever,  is  recorded  by  Mr. 
Gay,  in  the  'Pathological  Transactions'  of  1854.  The  patient,  set.  6, 
recovered. 

The  treatment  of  constipation  is  a  subject  of  great  interest,  because 
it  is  one  which  so  frequently  tests  the  skill  of  the  practitioner.  A 
knowledge  of  the  habits  and  diet  is  essential  to  us  in  devising  means 
of  cure;  thus  regular  exercise,  when  the  life  has  been  sedentary,  and 
especially  walking  or  horse  exercise,  is  of  paramount  importance. 
It  is  true  that  the  beneficial  effect  of  pure  air  may  be  otherwise 
obtained,  but  not  all  its  good  effects ;  for  carriage  exercise  is  not  alone 
sufficient.  The  practice  of  riding  in  many  of  the  crowded  convey- 
ances which  hurry  to  the  city  day  by  day,  becoming  wearied  by 
standing,  or  quietly  sitting  at  the  desk,  and  when  exhausted  return- 
ing home  in  a  close  omnibus,  or  railway  carriage,  is  sufficient  to 
induce  discomforts  of  a  hundred  kinds,  without  the  addition  of  the 

i  '  Medical  Gazette,'  p.  246.     1832-1833. 


41G  ON    CONSTIPATION. 

anxieties  of  life;  and  this  mode  of  life  in  a  greater  or  less  degree  is 
everywhere  observed.  An  actual  distaste  for  or  aversion  to  walking 
may  be  easily  acquired,  and  the  beneficial  effect  of  such  exercise  is 
forgotten. 

It  is  very  desirable  to  promote  constant  regularity  in  the  action 
of  the -bowels;  with  many  persons,  an  early  movement  before  or 
after  breakfast,  removes  discomfort  for  the  rest  of  the  day;  with 
others,  though  less  desirable,  the  time  immediately  before  going  to 
bed  is  chosen. 

The  character  of  the  food  is  an  important  consideration ;  sometimes 
injury  is  done  by  taking  more  than  the  frame  requires,  and  the 
stomach  can  digest;  or  by  too  great  sameness  in  the  diet,  for  variety 
is  required;  not  that  at  each  rneal  numerous  forms  of  food  should 
be  taken  and  satiety  induced  by  the  niceties  of  the  culinary  art ; 
but,  an  admixture  of  animal  and  vegetable  food  is  necessary,  and  a 
change  in  them  is  requisite. 

Vegetable  food  contains  a  large  quantity  of  indigestible  material 
and  of  alkaline  salts  which  stimulate  the  alimentary  canal,  so  that 
when  there  is  a  tendency  to  constipation,  a  free  use  of  this  form  of 
diet  may  be  sufficient  to  remove  it ;  thus,  brown  bread  acts  by  the 
irritating  character  of  the  indigestible  parts  of  the  grain.  Again, 
gentle  palpation  of  the  abdomen,  kneading  of  the  parietes  with  the 
palms  of  the  hands,  has  sometimes  induced  action.  The  bracing 
tonic  effect  of  a  shower-bath,  or  in  a  less  degree  of  cold  sponging, 
when  it  is  not  contra-indicated,  may  obviate  constipation.  These 
means  produce  their  effect  by  the  increased  action  of  the  abdominal 
muscles;  but  another  agent  acts  in  a  similar  manner,  namely,  elec- 
tricity. A  galvanic  current  transmitted  through  the  abdominal 
walls  induces  a  very  speedy  action,  or  rather  emptying  of  the  colon ; 
it  has  been  sometimes  recommended  in  the  constipation  of  painter's 
colic.  I  have  used  it  with  manifest  advantage  in  paralysis.  A  case 
of  partial  paraplegia,  in  which  injections  did  not  act  satisfactorily, 
and  drastic  purgatives  were  undesirable,  was  treated  by  a  galvanic 
current  passed  through  the  abdomen  every  morning ;  in  a  few  hours 
a  free  evacuation  was  produced  without  any  discomfort.  This  agent, 
which  has  been  employed  to  excite  contraction  of  the  uterus,  may  be 
frequently  used  with  benefit  in  constipation. 

Medicines,  directly  purgative,  may  be  divided  into  several  classes 
— those  which  are  :— 

1.  Laxatives. — Manna,  figs,  prunes,  raisins,  fruits,  brown  bread, 
cold  water. 

2.  Aperients. — Castor  oil,  almond  oil.  cod-liver  oil. 

3.  Saline  purgatives,  as  magnesia,  sulphate  of  soda,  and  of  potash, 
saline  waters,  bitartrate  of  potash,  &c. 

4.  Mild  purgatives. — Senna,  rhubarb,  aloes,  mercurial  medicines. 

5.  Drastic  purgatives. — Jalap,  colocynth,  gamboge,  scarnmony,  tur- 
pentine, croton  oil,  elaterium. 

Inspissated  bile  has  been  used  as  an  aperient,  from  the  idea  that 
the  excrementitious  portion  of  bile  is  naturally  purgative  in  its 
action ;  but  although  ten  or  fifteen  grains  may  act  as  an  aperient, 


OX    CONSTIPATION.  417 

and  assist  in  unloading  the  intestine,  it  is  an  offensive  and  less  satis- 
factory  remedy  than  others  which  we  possess.  These  remedies  act 
on  different  portions  of  the  intestine  and  in  various  ways ;  thus 
mercurial  purgatives  stimulate  all  the  secretions,  both  those  of  the 
liver1  and  of  the  mucous  membrane ;  senna,  and  saline  purgatives 
act  on  the  small  intestine,  and  render  the  evacuations  more3 fluid ; 
aloes,  and  the  drastic  purgatives  act  on  the  colon  ;  rhubarb  has  an 
astringent  as  well  as  purgative  effect,  and  sometimes  irritates  and 
offends  the  stomach.  Some  aperients  stimulate  the  intestine  to  in- 
creased peristaltic  action  and  excite  griping  pain.  The  action  of  the 
salines  is  partly  due  to  exosmotic  current  from  the  capillaries  of  the 
intestine,  thus  leading  to  the  effusion  of  fluid  in  a  greater  extent 
into  the  canal  than  is  absorbed  from  it. 

The  rapidity  of  the  action  of  aperients  is  also  very  diverse.     The 

_  salines  act  quickly,  especially  if  given  with  a  considerable  quantity 

of  diluent  fluid.     Aloes  is  slow  in  its  action,  and  requires  several 

hours  to  produce  any  effect.     Drastic  purgatives  are  often  followed 

by  much  trying  irritation  in  the  rectum,  and  by  tenesmus. 

Strychnia,  or  nux  vornica,  is  a  valuable  remedy  in  constipation; 
it  excites  the  muscular  coat  to  contraction,  at  the  same  time  that  a 
tonic  effect  is  produced  on  the  mucous  membrane.  It  is  well  to 
combine  with  it  purgatives  and  sedatives,  as  aloes,  and  henbane,  &c. 
Preparations  of  steel  often  act  as  purgatives  in  the  same  manner. 

Podophyllin,  from  the  Podophyllum  peltatum,  the  May  apple  or 
mandrake,  has  been  long  used  in  the  United  States ;  in  doses  of  gr. 
J-j,  it  acts  as  a  mild  purgative,  producing  an  evacuation  from  the 
bowels  slowly,  but  efficiently  and  often  without  pain.  I  have  ob- 
served it  act  thus  favorably  in  chronic  ulcer  of  the  stomach ;  in 
large  doses  it  produces  violent  vomiting  and  purging ;  thus  in  an 
instance  in  which  a  nurse,  contrary  to  directions,  gave  seven  to  ten 
grains,  severe  colic,  vomiting  and  dysenteric  diarrhoea  followed,  but 
subsided  in  a  few  days.  The  tincture  of  podophyllin,  gr.  j,  with  5j 
of  rectified  spirit,  is  a  convenient  mode  of  administering  this  purga- 
tive. 

The  use  of  glysters  is  too  frequently  neglected  in  ordinary  consti- 
pation ;  but,  their  beneficial  effect  is  now  more  generally  acknow- 
ledged ;  some  act  simply  by  irritating  and  distending  the  intestine, 
thus  exciting  it  to  contract ;  as  warm  water  and  gruel ;  purgative 
substances  may  be  added,  as  soap,  castor  oil,  colocynth,  turpentine, 
and  rue ;  the  last  two  are  especially  used  when  constipation  is  asso- 
ciated with  flatulent  distension  of  the  intestines.  The  excessive  use 
of  glysters  even  of  the  mildest  kind,  as  water  and  gruel,  and  espe- 
cially when  they  are  administered  in  large  quantities,  induces  dis- 
tension of  the  rectum,  and  an  unreadiness  to  act  without  the  wonted 
stimulus. 

I  cannot  leave  the  subject  of  the  use  of  purgatives  in  ordinary 
constipation,  without  speaking  of  the  injurious  effect  of  their  indis- 

1  The  results  obtained  by  the  Committee  of  the  British  Medical  Association  appear, 
however,  to  show  that  mercurial  medicines  do  not  increase  the  actual  flow  of  bile  in 
the  lower  animals. 
27 


418  ON    CONSTIPATION. 

criminate  and  injudicious  use;  to  some  the  use  of  a  dinner  pill  or 
;iii  aiu-rifiil  at  night,  is  constant,  year  after  year;  in  others  a  slight 
discomfort  leads  to  the  use  of  the  blue  pill  or  black  draught,  or  to 
still  more  active  agents.  Temporary  relief  is  afforded  by  powerful 
purgatives,  but  the  delicate  mucous  membrane  of  the  intestinal  tract 
is  weakened,  a  state  of  chronic  catarrh  is  induced,  and  the  very  con- 
dition sought  to  be  removed  is  aggravated  tenfold.  In  enfeebled 
persons,  violent  purgative  medicine  has  in  very  many  cases  induced 
excessive  prostration,  and  even  fatal  results;  and,  in  them,  it  is  easy 
to  excite  a  state  of  irritation  which  it  is  almost  impossible  to  subdue. 

The  administration  of  vegetable  tonics,  with  mild  purgative  medi- 
cines, and  with  ammonia,  is  often  of  great  utility;  a  valuable  pre- 
paration of  this  kind  is  the  compound  gentian  mixture  of  the  London 
Pharm.;  it  contains  senna,  gentian,  orange  and  lemon  peel,  ginger, 
and  tincture  of  cardamoms.  The  combination  of  aloes  and  rnyrrh  is 
a  preparation  of  a  somewhat  similar  kind,  the  tonic  effect  of  the 
myrrh  is  associated  with  the  purgative  of  the  aloes.  Purgative 
medicines  sometimes  act  more  beneficially  in  combination;  as  slight 
mercurials,  when  the  secretions  of  the  liver  are  imperfect,  with  aloes, 
rhubarb,  and  colocynth. 

The  addition  of  an  anodyne  or  carminative,  as  hyoscyamus,  Dover's 
powder,  the  essential  oils,  &c.,  with  more  active  remedies,  is  benefi- 
cial in  removing  their  irritating  character,  and  in  preventing  the 
griping  pain  sometimes  induced  by  them  when  given  alone;  thus 
the  compound  gamboge  pill,  and  compound  colocynth  pill  with  hen- 
bane, act  as  efficient  but  tolerably  mild  purgatives,  emptying  the 
large  intestine;  or  the  purgative  may  be  sheathed  by  mucilaginous 
and  oleaginous  substances,  as  rhubarb  with  linseed  oil.  Belladonna 
will  often  act  as  a  purgative  when  administered  alone,  as  gr.  J  of 
the  extract;  it  appears  to  induce  this  action  by  lessening  spasmodic 
irritation. 

In  infants,  constipation  is  sometimes  an  exceedingly  troublesome 
affection;  the  repetition  of  castor  oil  is  trying,  and  even  injurious; 
an  old-fashioned  remedy  is  that  of  exciting  the  intestine  to  contract 
by  introducing  a  very  small  glyster  pipe  into  the  rectum,  or  a  por- 
tion of  soap  cut  into  a  conical  shape;  magnesia  may  be  given  in  a 
tasteless  form,  the  calcined,  or  citrate,  &c.,  or  sometimes  a  small 
quantity  of  gruel  will  excite  the  bowel  to  slight  action;  in  any  case, 
however,  irritating  medicine  must  be  avoided.  It  is  difficult  to 
over-estimate  the  injurious  effect  in  children  of  repeated  doses  of 
calomel,  of  jalap,  &c.;  muco-enteritis  is  induced,  and  sometimes 
fatal  results  follow;  scammony  with  milk  is  a  convenient  remedy  in 
some  cases,  but  it  must  be  used  with  caution. 

In  the  aged,  enfeebled  either  by  a  life  of  activity  or  by  declining 
strength,  the  intestines  lose  their  normal  power  of  wonted  contrac- 
tion; to  use  drastic  purgatives  is  out  of  the  question,  and  a  constant 
change  of  milder  aperients  is  necessary.  The  mildest  laxatives  may 
suffice,  as  a  draught  of  cold  water,  prunes,  figs,  roasted  apples,  brown 
bread,  manna,  the  confection  of  senna,  or  the  compound  rhubarb 
pill,  alone  or  with  henbane,  so  the  compound  colocynth  pill,  and 


ON    CONSTIPATION.  419 

scammony  pill  with  henbane  and  Dover's  powder,  or  a  few  grains  of 
dried  rhubarb  with  capsicum  and  soap,  may  be  given  with  each 
principal  meal;  and  to  these,  in  some  instances,  very  minute  doses 
of  strychnia  are  added,  with  considerable  benefit.  The  arnmoniated 
tincture  of  guaiacum  is  sometimes  useful  as  a  stimulant  to  the  colon, 
or  the  powdered  resin  of  guaiacum  combined  with  the  confection  and 
syrup  of  senna,  or  may  be  confection  of  sulphur. 

When  the  muscular  coat  of  the  rectum  loses  its  contractile  energy 
the  contents  sometimes  become  so  impacted  and  hardened  as  subse- 
quently to  withstand  the  most  powerful  efforts  at  expulsion ;  purga- 
tives, and  even  copious  injections,  are  insufficient  to  soften  the  hard 
contents,  and  mechanical  assistance  has  in  not  a  few  cases  been  re- 
quired. Hard  masses  may  be  retained  in  the  colon  and  rectum  even 
although  there  be  repeated  action  of  a  fluid  kind ;  for,  laterally, 
fluid  may  pass,  especially  after  purgative  remedies,  whilst  scyba'la 
are  still  retained.  In  advanced  life,  in  spinal  disease,  in  constipation 
after  powerful  purgatives,  this  state  is  occasionally  present,  but  it 
has  in  rare  cases  been  witnessed  in  very  early  life.  Warm  copious 
injections,  whilst  enteric  irritation  is  avoided,  will  suffice  to  relieve 
most  of  these  impactions,  but  it  is  well  to  precede  the  soap  or  gruel 
injection  with  several  ounces  or  even  a  pint  of  warm  salad  oil,  if  the 
obstruction  be  severe. 

Concretions  may  form  in  the  intestines  from  deposit  upon  extra- 
neous substances,  from  impacted  biliary  calculi,  but  more  frequently 
they  consist  of  hardened  feces,  or  of  the  undigested  portions  of  food 
and  medicine,  as  from  oatmeal,  brown  bread,  &c.  Dr.  Harley,  in 
an  interesting  communication  on  this  subject  to  the  Pathological 
Society,  in  1859,  records  an  instance  of  concretion  consisting  of  starch, 
taken  to  relieve  dysentery;  another  of  benzoin,  which  had  been 
taken  to  improve  the  voice,  and  had  formed  a  concretion  as  large  as 
a  bean.  Again,  large  quantities  of  magnesia  have  been  found  as  a 
mass  in  the  colon,  and  portions  of  string  have  become  impacted  in 
like  manner. 

Foreign  bodies  of  considerable  size  sometimes  pass  through  the 
whole  intestinal  canal  without  producing  any  injurious  symptoms, 
as  coins  accidentally  swallowed,  stones  taken  by  maniacs ;  in  other 
cases  they  are  retained  at  the  sphincter  and  require  mechanical 
assistance  in  their  removal,  as  fish-bones,  &c.,  placed  across  the 
intestine. 

In  a  remarkable  instance  in  which  a  sailor  swallowed  clasp-knives, 
several  were  discharged  from  the  bowels,  and  one  was  found  fixed 
transversely  in  the  rectum ;  the  case  is  recorded  by  Dr.  Marcet,  in 
the  'Medico-Chirurgical  Transactions,'  and  the  thickened  stomach, 
with  the  fragments  of  the  blades  found  on  examination  after  death, 
are  preserved  in  the  Museum  of  Guy's  Hospital.  The  patient  was 
an  American  sailor,  aged  23,  who,  in  June,  1799,  swallowed  four 
clasp-knives ;  three  were  discharged  from  the  bowels.  In  March, 
1805,  he  swallowed  fourteen  knives  in  two  days ;  in  December,  1805, 
he  swallowed  fifteen  to  twenty  more ;  making  thirty-five  swallowed 
at  different  times.  His  health  became  impaired;  he  vomited  the 


420  ON    CONSTIPATION. 

handle  of  one,  and  passed  portions  of  the  blades  of  others;  and  in 
MM rch,  1809,  he  died  in  a  state  of  extreme  exhaustion.  The  oesopha- 
gus and  stomach  were  dilated  and  thickened,  and  in  the  latter,  there 
were  numerous  blades  of  knives  partially  dissolved.  In  the  abdo- 
men there  was  a  general  discoloration  of  the  intestines ;  one  blade 
was  found  perforating  the  colon  opposite  the  kidney,  but  without 
extravasation  of  feces ;  another  blade  was  transversely  fixed  in  the 
rectum. 


421 


CHAPTER  XYI. 

ORGANIC  OBSTRUCTION— INTERNAL  STRANGULATION— INTUSSUSCEPTION 
—CARCINOMA  OF  INTESTINE. 

VARIED  conditions,  leading  to  insuperable  constipation,  have  fre- 
quently been  indiscriminately  associated  together,  under  the  terra 
ileus  ;  and,  whilst  we  are  willing  to  acknowledge,  that  very  great 
difficulty  is  connected  with  the  correct  diagnosis  of  these  cases,  we 
believed  that  when  a  full  history  of  the  symptoms  can  be  obtained, 
careful  examination  will  enable  us  to  divide  them  into  several  classes, 
and  to  make  an  approximate  diagnosis,  not  only  as  to  the  character, 
but  as  to  the  position  of  the  obstruction.  Each  minute  circumstance 
is  important  in  assisting  the  correct  diagnosis  of  these  cases,  the 
accurate  detail  of  previous  symptoms,  the  mode  of  attack,  the  posi- 
tion of  the  pain,  the  vomiting,  the  relative  severity  and  period  of 
commencement  of  these  symptoms,  the  state  of  the  abdomen,  the 
general  appearance  of  the  patient,  the  quantity  of  the  urine,  &c.  Dr. 
Barlow  has  drawn  attention  to  several  of  these  conditions,  and  has 
shown  the  importance  of  ascertaining  the  period  of  the  commence- 
ment of  the  vomiting1  and  the  condition  of  the  renal  secretion. 

Organic  obstruction  of  the  bowel  may  be  conveniently  divided  into 
several  classes. 

1.  Those  cases  in  which  the  cause  of  the  obstruction  is  external  to 
the  bowel  comprising  : — 

Bands  of  adhesion. 

Diverticula. 

Adherent  appendix  ceeci. 

Twists  of  the  bowel  or  displacement. 

External  tumors  and  enlarged  glands. 

Internal  hernia : — 

Diaphragmatic. 

Meso-colic. 

Ornental. 

Obturator. 

Pelvic. 

2.  Those  cases  in  which  the  cause  of  the  obstruction  is  in  the 
changed  coats  of  the  intestine. 

Intussusception. 

Polypoid  growths. 

Cancerous  disease. 

Cicatrices. 

Contraction  following  inflammation  or  injury. 

1  'Guy's  Reports,'  1844.     Clinical  cases.     Practice  of  Medicine. 


422  INTERNAL    STRANGULATION. 

Peritonitis  and  enteritis. 

Prolapsus  ani. 

Inflamed  hemorrhoids. 

3.  Those  cases  in  which  the  obstruction  is  due  to  the  contents  of 
the  bowel. 

Concretions. 

Foreign  bodies,  gall  stones. 

Impacted  fec6s. 

In  the  consideration  of  the  pathology  of  the  first  class  of  cases, 
those  in  which  the  obstruction  is  external  to  the  bowel,  we  have  first  to 
notice  the  obstruction  produced  by  bands  of  adhesion. 

These  bands  are  of  various  kinds,  sometimes  like  a  thin  cord 
under  which  a  coil  of  intestine  may  have  passed  or  round  which 
the  intestine  may  have  twisted ;  at  other  times  they  are  broad, 
and  may  be  the  cause  of  obstruction  by  having  become  perforated 
or  by  allowing  the  intestine  to  pass  through  them,  but  more  fre- 
quently the  obstruction  is  due  to  traction  upon  the  band  by  disten- 
sion of  the  part  above.  Thus,  in  an  instance  under  my  care,  there 
was  a  broad  band  extending  from  nearly  the  whole  of  the  ascending 
colon  to  the  mesentery;  years  had  passed  with  only  slight  pain 
when  the  knee  and  thigh  were  strongly  flexed,  but  when  the  caecum 
became  greatly  distended  after  improper  food,  the  traction  upon  the 
band  led  to  complete  and  fatal  obstruction.  Bands  are  generally 
the  result  of  inflammatory  action,  and  may  extend  from  one  coil  of 
the  small  intestine  to  another,  from  the  small  to  the  large  intestine, 
from  the  sigmoid  flexure  to  the  caecum,  from  the  small  intestine  to 
the  pelvic  viscera,  as  the  uterus  or  ovary ;  again  a  portion  of  adhe- 
rent omentum  may  constitute  the  constricting  band.  The  inflam- 
mation may  have  taken  place  during  infantile  or  even  during  foetal 
life,  and  it  is  always  important  to  inquire  minutely  into  the  clinical 
history  in  these  cases. 

The  part  of  the  small  intestine  most  frequently  strangulated  either 
by  loops,  bands,  or  adhesions,  is  the  lower  portion  of  the  ileum ;  the 
colon  is  sometimes  constricted  by  old  inflammatory  bands,  but  the 
sigmoid  flexure  is  that  part  which  we  find  most  commonly  diseased, 
and  very  frequently  the  disease  there  is  of  a  cancerous  character; 
sometimes  the  constriction  is  twofold,  as  in  an  instance  under  the 
care  of  Dr.  Bees,  in  Guy's  Hospital,  in  which  a  band  constricted  the 
upper  part  of  the  jejunum,  and  a  second  band  the  ileum. 

The  constricting  medium  may  however  arise  from  congenital  mal- 
formation, and  be  produced  by  diverticula.  During  foetal  life  the 
ornphalo-mesenteric  duct  extends  from  the  intestine  to  the  umbilicus, 
and  a  portion  of  this  duct  may  remain  as  a  pouch  passing  from  the 
ileum  a  few  inches  from  its  union  with  the  caecum.  At  the  extremity 
of  this  pouch  an  adhesion  of  varying  length  may  fix  it  either  to  the 
mesentery,  to  the  umbilicus,  or  to  a  coil  of  intestine,  and  thus  become 
a  constricting  band.  Remains  of  this  duct  may  be  free  from  the 
ileum,  but  attached  at  the  navel. 

The  appendix  cseci,  as  we  have  before  remarked,  varies  greatly  in 
its  position  and  in  its  length.  It  is  sometimes  several  inches  long 


INTERNAL    STRANGULATION.  423 

and  free,  so  that  it  may  pass  over  a  coil  of  intestine,  and  if  inflam- 
matory adhesion  take  place  it  may  become  a  constricting  band;  we 
have  known  the  lower  part  of  the  ileum  completely  bound  down  in 
this  manner. 

Tivists  of  the  bowel  and  displacement  frequently  become  the  cause 
of  obstruction,  and  the  intestine  may  be  looped  in  a  complicated 
manner.  Eokitansky  gives  three  forms  of  twisting  of  the  intes- 
tine:— 1,  upon  its _ own  axis;  2,  upon  the  mesentery;  and  3,  upon 
other  coils  of  the  intestine.  The  small  intestine  may  easily  become 
thus  twisted,  and  the  caecum  is  sometimes  so  freely  movable  that  it 
may  be  twisted  round  into  the  left  hypochondrium,  as  in  a  case 
recorded  in  this  chapter.  Again,  the  sigmoid  flexure,  especially  in 
aged  persons,  where  there  has  been  previous  constipation,  will  bend 
upon  itself,  and  fall  over  into  the  pelvis.  The  sigmoid  flexure  then 
forms  an  acute  angle  opposite  to  the  brim  of  the  pelvis,  and  the 
contents  will  not  pass;  the  distension  of  the  upper  part  of  the  bowel 
increases  the  obstruction. 

The  pressure  of  enlarged  glands  and  of  abdominal  tumors  is  an 
occasional  source  of  insuperable  constipation.  An  ovarian  tumor 
may  exert  considerable  pressure  on  the  bowel,  but  if  a  coil  of  intes- 
tine has  become  fixed  by  inflammatory  adhesion  the  obstruction  may 
be  rendered  complete.  It  is  more  frequent  to  find  that  tumors  which 
cause  fatal  obstruction  are  of  a  cancerous  character;  in  a  case  under 
the  care  of  one  of  my  colleagues,  numerous  enlarged  glands  pressed 
upon  the  intestine  and  produced  a  double  obstruction,  one  affecting 
the  lower  part  of  the  intestine,  and  the  other  the  duodenum,  in  which 
latter  part  the  bowel  passed  between  two  enlarged  glands  which 
compressed  it  on  either  side. 

By  internal  hernia  we  mean  those  forms  of  the  disease  in  which 
the  intestine  does  not  protrude  in  the  ordinary  channels  as  through 
the  umbilicus,  the  inguinal  canal,  or  the  femoral  ring,  but  in  posi- 
tions where  it  is  either  entirely  hidden  by  the  soft  structures,  or 
concealed  in  the  abdomen;  thus  hernia  may  take  place  through  the 
diaphragm,  but  many  of  these  cases  are  from  direct  violence  and  a 
fatal  result  at  once  ensues;  the  protrusion  may  be  through  the  meso- 
colon,  through  the  oinentum  or  the  mesentery;  or  again  through  the 
obturator  foramen,  the  ischiatic  notch,  or  through  the  recto- vaginal 
pouch,  or  lastly  through  the  foramen  of  Winslow,  or  behind  the 
peritoneum. 

A  second  division  is  that  in  which  there  is  change  in  the  coats  of 
the  intestine  itself.  Such  is  the  case  in  intussusception;  and  also  in 
cancerous  disease  of  the  bowel  whether  of  the  large  or  small  intestine. 
Polypi  of  varied  form  and  size  grow  from  the  mucous  membrane, 
especially  in  the  rectum  and  sigmoid  flexure;  these  growths  some- 
times induce  intussusception,  but  they  may  themselves  produce  ob- 
struction. The  cicatrices  which  follow  ulcerative  action  may  cause 
occlusion,  for  not  only  is  the  bowel  narrowed  at  that  part,  but  spas- 
modic contraction  may  ensue  and  render  the  partial  obstruction 
complete ;  in  this  way  we  have  observed  an  ulcer  in  the  small  intes- 
tine lead  to  fatal  result.  After  dysentery  the  cicatrices  are  still 


424  INTERNAL    STRANGULATION. 

more  decided,  and  constipation  even  of  an  insuperable  character 
may  ensue;  malignant  deposit  sometimes  takes  place  at  the  seat  of 
the  cicatrix.  The  same  kind  of  contraction  may  be  induced  by 
previous  inflammation  whether  the  result  of  injury  or  not. 

In  peritonitis  and  enteritis,  the  coats  ot  the  intestine  are  enfeebled 
by  the  inflammatory  process :  they  are  unable  to  contract  and  to 
propel  onwards  the  contents,  hence  constipation  that  is  apparently 
insuperable  is  the  result;  a  greater  mistake  can  scarcely  be  made 
than  to  administer  purgatives  in  these  cases,  and  to  try  and  induce 
action  from  the  bowels.  In  procident  conditions  of  the  rectum,  pro- 
lapsus ani,  and  in  inflamed  haemorrhoids,  fatal  constipation  may  some- 
times result;  the  pain  is  so  severe  that  the  patient  will  not  allow 
the  bowels  to  act;  and  vomiting  and  extreme  prostration  may  come  on. 

A  third  class  includes  those  cases  in  which  the  obstruction  arises 
from  the  nature  of  the  contents  of  the  bowel ;  we  have  already 
referred  to  concretions  of  various  kinds,  and  to  foreign  bodies,  stones, 
fish  bones,  portions  of  hair  and  string.  It  is  not  usual,  however, 
for  these  substances  to  cause  fatal  obstruction,  and,  indeed,  it  is  re- 
markable how  foreign  bodies  will  pass  along  the  intestinal  tract  with 
comparatively  little  irritation,  such  as  coins  of  varied  sizes,  nails, 
pins,  even  small  spoons,  &c. 

Gall  stones  of  very  large  size  occasionally  obstruct  the  bowel;  we 
remember  fatal  obstruction  from  a  gall  stone  impacted  in  the  com- 
mencement of  the  jejunum,  and  in  another  case  which  we  have 
recorded,  the  gall  stone  was  gradually  working  its  way  onward  to 
the  colon,  it  had  reached  the  lower  part  of  the  ileum,  when  death 
took  place  from  hemorrhage.  There  are  many  instances  on  record 
of  this  kind  of  obstruction.  Fecal  accumulation  rarely  if  ever 
causes  fatal  obstruction,  though  death  may  arise  from  the  violent 
remedies  employed,  as  from  strong  purgatives  or  as  when  the  injec- 
tions of  very  large  quantities  of  fluid  have  been  followed  by  fatal 
collapse. 

\Vhen  the  obstruction  is  complete,  the  intestine  above  the  part 
becomes  distended,  and  when  the  disease  is  chronic,  the  muscular 
coat  becomes  hypertrophied.  In  chronic  obstruction,  especially  in 
the  lower  part  of  the  colon,  the  distension  becomes  very  great,  and 
the  colon  attains  an  enormous  size.  The  coats  of  the  intestine  at 
the  seat  of  the  stricture  become  greatly  congested ;  there  is  intense 
venous  repletion ;  the  mucous  membrane  becomes  purplish  in  color, 
enteritis  supervenes  and  afterwards  ulceration.  The  inflammatory 
action  extends  to  the  peritoneum,  so  that  it  is  very  rare  to  find  a 
case  of  fatal  obstruction  without  peritonitis ;  sometimes  merely  a  dry 
and  congested  state  of  the  serous  membrane  exists,  in  others  lymph 
is  effused,  and  in  many  there  is  perforation.  The  perforation  of  the 
intestine  is  often  observed  at  the  seat  of  the  constriction,  and  is  most 
marked  at  its  upper  limit;  but  in  diseased  rectum  and  sigmoid  flex- 
ure, it  will  be  frequently  found  that  perforation  has  taken  place,  not 
only  at  the  constriction,  but  at  the  eoecurn.  The  ulceration  of  the 
mucous  membrane  in  these  instances  is  also  peculiar;  it  is  somewhat 
similar  to  that  presented  by  the  skin  which  has  been  overstretched, 
and  affected  with  erythematous  inflammation  and  superficial  ulcera- 


INTERNAL    STRANGULATION.  425 

tion.  It  is,  in  instances  where  the  obstruction  is  primarily  from  the 
mucous  membrane,  as  in  cancerous  growth,  that  peritonitis  is  most 
slowly  developed.  Where  all  the  coats  of  the  intestine  are  in- 
volved, as  in  many  cases  of  internal  strangulation,  the  vessels  of  the 
mesentery  become  also  obstructed,  oedema  is  produced,  and  in  a 
short  time  gangrene  follows. 

In  the  records  of  the  Guy's  post-mortem  room  during  twenty-three 
years,  there  have  been  nearly  8000  examinations  (7934),  and  twenty- 
five  instances  of  fatal  obstruction  by  bands  are  described. 

In  10  a  peritoneal  band  extended  from  the  mesentery  to  some 
other  part. 

In  5  there  was  an  omental  band. 

"      2  a  band  from  the  vermiform  appendix. 

"      5  diverticula  ilei. 

"  3  various;  in  one  there  was  an  arch  from  the  mesentery;  in 
a  2d,  the  pedicle  of  an  ovarian  tumor;  and  in  the  3d,  the  neck  of  an 
internal  hernial  pouch  formed  the  constricting  medium. 

From  the  whole  number  of  post  mortems  just  mentioned  there  were 
114  cases  of  intestinal  obstruction,  including  strictures  of  various 
kinds ;  there  were  intussusceptions  17  times.  Twisting  of  volvulus 
8  times.  Obstruction  by  bands  25  times.  Adhesions  and  contrac- 
tions 20  times. 

The  latter  class  included  various  conditions,  such  as  chronic 
tubercular  peritonitis  twisting  upon  old  adhesions,  one  case  of  ob- 
struction some  time  after  recovery  from  intussusception,  and  two 
other  cases  were  from  a  malposition  or  malformation. 

As  regards  the  symptoms  produced  in  these  several  conditions  we 
find,  that  the  instances  of  internal  strangulation  and  acute  obstruc- 
tion of  the  bowels,  from  twisting  or  compression,  differ  from  those 
produced  by  intussusception  and  from  the  more  gradual  disease  due 
to  cancerous  growth,  and  we  may  take  these  three  as  examples  of  the 
several  varieties  we  have  just  enumerated. 

Abercrombie1  describes  cases  of  ileus  in  which  no  cause  of  strangu- 
lation nor  obstruction  was  detected  after  death,  and  he  believed  them 
to  arise  from  distension,  or  "  simple  derangement  of  action"  of  the 
intestine;  thus  he  states,  "that  distension  appears  to  constitute  a 
morbid  condition  which  inay  be  fatal  without  passing  into  any 
farther  state  of  disease;"  and  again,  that  "ileus  does  not  appear  to 
be  necessarily  connected  with  obstruction  in  any  part  of  the  canal ; 
for  we  have  seen  it  fatal  without  obstruction,  and  we  have  seen 
everything  like  obstruction  entirely  removed  without  relieving  the 
symptoms."  He  mentions  other  instances  in  which  adhesions  had 
formed  without  sensible  diminution  of  the  calibre  of  the  intestine, 
and  which  were  followed  by  the  symptoms  of  insuperable  obstruc- 
tion ;  in  the  former  we  believe  that  either  enteritis  was  present,  or 
the  bowel  was  twisted;  in  the  latter  that  spasmodic  contraction 
rendered  a  partial  impediment  complete ;  and  the  author  just  men- 
tioned writes,  "I  admit,  however,  that  there  may  be  irregular  con- 

1  Abercrombie  on  '  Diseases  of  the  Stomach  and  Intestine.'     Third  edition. 


426  INTERNAL    STRANGULATION. 

tractions  of  portions  of  the  intestine,  analogous  to  that  to  which  the 
term  spasm  is  usually  applied,  and  that  these  may  form  the  first 
step  in  that  chain  of  derangements  of  the  harmonious  action  of  the 
canal  which  leads  to  an  attack  of  ileus." 

Internal  strangulation. — The  general  symptoms  of  this  condition 
are  pain,  gradually  increasing  distension  of  the  abdomen,  constipa- 
tion, generally  of  an  insuperable  character,  vomiting  at  first  bilious, 
afterwards  stercoraceous ;  and  after  a  longer  or  shorter  period  peri- 
tonitis, prostration,  and  death. 

Pain. — In  many  cases  of  internal  strangulation  there  is  a  sudden 
catch  in  the  bowels,  as  of  some  displacement,  and  the  patient  can 
place  the  hand  on  the  exact  part,  which  generally  indicates  the  seat 
of  disease,  although  we  may  afterwards  find  that  distension  and  other 
causes  have  led  to  considerable  alteration  of  its  original  position. 
When  a  portion  of  intestine  has  slipped  under  a  band  of  adhesion, 
or  into  a  hole  of  omentum  or  mesentery,  this  character  of  pain  is 
observed,  but  when  there  has  been  a  twist  of  the  intestine  the  pain 
is  generally  more  gradual  in  its  development,  and  for  many  days 
may  be  entirely  absent.  The  most  obscure  cases  are  those  of  inter- 
nal strangulation,  in  which  there  has  been  chronic  partial  constric- 
tion, when  from  indiscretions  in  diet,  or  other  causes  slight  enteric 
irritation  has  led  to  spasmodic  constriction  at  the  part ;  in  these 
cases  the  pain  closely  resembles  ordinary  colic.  Tenderness  of  the 
abdomen  may  be  absent  for  many  days ;  in  some  instances  the  peri- 
tonitis does  not  come  on  till  nearly  the  close  of  life,  when  it  is  due 
to  a  state  of  continued  and  extreme  distension  of  the  intestine,  and 
to  ulceration  of  the  mucous  membrane  extending  to  the  serous  coatj 
but  where  there  has  been  sudden  strangulation,  the  serous  membrane 
is  more  quickly  implicated,  and  the  symptoms  bear  a  closer  resem- 
blance to  those  of  ordinary  external  strangulated  hernia.  If  the 
strangulation  be  in  the  small  intestine,  either  near  the  caecum,  or  in  the 
jejunum,  the  pain  will  generally  be  found  to  be  in  the  region  of  the 
umbilicus ;  where  the  colon  is  involved  the  position  of  the  pain  is  in 
the  course  of  that  part  of  the  intestine,  and  often  marks  its  precise 
seat ;  thus,  in  diseases  of  the  sigmoid  flexure,  the  pain  will  generally 
be  found  in  the  left  iliac  fossa  or  in  the  left  groin. 

Peristaltic  movements. — Tympanitis. — Unless  the  obstruction  be 
very  high  in  the  alimentary  canal,  as  in  the  case  recorded  with  dis- 
ease of  the  duodenum  and  of  obstruction  twenty  inches  from  the 
pylorus,  the  abdomen  gradually  becomes  distended,  and  tympanitic 
on  percussion.  The  enlarged  coils  of  intestine  may  be  observed 
through  the  stretched  parietes,  and  the  peristaltic  movements  are 
often  clearly  perceptible,  especially  in  obstruction  of  the  colon.  If 
the  ileum,  or  the  commencement  of  the  ascending  colon  be  con- 
stricted, the  distension  is  central  in  its  character,  and  is  less  evident; 
but  if  the  descending  colon,  sigmoid  flexure,  or  rectum,  then  the 
portions  of  the  large  intestine  above  the  seat  of  disease  become 
greatly  distended ;  they  may  be  observed  in  the  peculiar  outline  of 
the  abdomen,  and  the  tympanitic  resonance  extends  to  the  loins; 
where,  however,  the  obstruction  arises  from  portions  of  twisted  large 


INTERNAL    STRANGULATION.  427 

intestine,  as  of  the  caacum  or  sigmoid  flexure,  we  find  that  there  is 
some  deviation  from  the  general  character  just  mentioned  ;  an  enor- 
mously distended  caecum  may  be  twisted  over  to  the  left  hypochon- 
driurn,  and  constitute  a  prominence  in  that  region.  It  is,  however 
not  to  be  considered  that  a  constant  rule  is  laid  down,  for  a  greatly 
distended  small  intestine  may  occupy  the  position  of  the  transverse 
colon. 

Vomiting.— The  character  of  the  vomiting,  and  the  period  at  which 
it  has  commenced,  especially  when  irritating  and  powerful  purgative 
medicines  have  not  been  administered,  are  important  guides  to  our 
diagnosis.      If  the  obstruction  be  sudden,  and  be  situated  in  the 
small  intestine,  the  vomiting  comes  on  very  quickly,  in  from  half 
an  hour  to  two  or  three  hours;   if  it  be  high  in  the  jejunum,  the 
vomited  matters  are  of  a  bilious  character,  but  if  near  to  the  caecum 
they  may  assume  a  fecal  odor,  and  be  completely  stercoraceous.     In 
one  instance,  in  which  the  obstruction  arose  from  a  band  of  adhesion 
high  up  in  the  jejunum,  the  vomiting  was  so  sudden  as  to  resemble 
that  produced  by  cerebral  disease;  and  this  view  of  the  case  was 
favored   by  the  partial  insensibility  of  the  patient.     In  the  case 
recorded  of  twisted  caecum,  where  the  obstruction  was  near  the  ter- 
mination of  the  ileum,  so  fully  fecal  was  the  character  of  the  vomited 
fluid  that  it  was  for  a  time  supposed  that  a  communication  existed 
between  the  stomach  and  the  transverse  colon.     When  the  large 
intestine  is  the  seat  of  disease,  as  in  cancer  of  the  sigmoid  flexure, 
and  of  the  rectum,  &c.,  several  days  sometimes  elapse  before  vomit- 
ing supervenes;  the  time  is,  however,  much  accelerated  if  powerful 
drastics  are  given.     In  the  latter  state,  also,  the  vomiting  is  more 
easily  checked  by  the  administration  of  remedies,  as  of  ice  and 
opium.     As  to  the  immediate  cause  of  stercoraceous  vomiting,  Dr. 
Brinton,  in  his  valuable  remarks  in  the  'Encyclopaedia  of  Anatomy,' 
has  suggested  that  the  peristaltic  action  is  not  in  itself  reversed,  but 
that  the  contents  of  the  bowel  are  propelled  onwards  in  their  normal 
manner  till  the  obstruction  is  reached,  when  the  fluid  assumes  a 
central  retrograde  direction,   thus  producing  a  double  'current,  a 
parietal  or  onward,  and  a  central  or  reverse  current;  this  retrograde 
movement  continues  till  the  vomited  matters  are  of  the  same  char- 
acter as  those  found  at  the  seat  of  stricture.     It  would,  however, 
seem,  from  the  character  of  the  ejection,  that  the  intestinal  tract  is 
emptied  in  the  order  of  its  anatomical  arrangement,  first  the  stomach, 
then  the  duodenum,  jejunum,  and  lastly  the  ileum.     During  the 
latter  stage  of  the  disease  if  the  patient  become  insensible,  regurgi- 
tation  of  the  stercoraceous  vomit  sometimes  takes  place  into  the 
trachea  and  bronchi. 

Hiccough  is  also  more  severe  and  more  speedily  produced  in  the 
strangulation  of  the  small  than  of  the  large  intestine.  It  must  be 
borne  in  mind,  that  the  vomiting  and  hiccough  are  sometimes  ex- 
treme in  peritonitis,  especially  where  the  serous  membrane  of  the 
stomach  is  involved. 

Urine. — Dr.  Barlow  has  drawn  especial  attention  to  the  amount 
of  urine  excreted,  as  a  sign  of  the  seat  of  obstruction ;  that  where 


428  INTERNAL    STRANGULATION. 

the  obstruction  is  high  in  the  canal,  as  in  the  jejunum  or  ileum, 
absorption  is  partially  checked,  the  renal  blood  supply  is  thereby 
considerably  diminished,  and  a  small  quantity  of  urine  is  excreted ; 
if,  on  the  contrary,  the  rectum  or  sigmoid  flexure  be  occluded,  nearly 
the  whole  of  the  capillaries  of  the  alimentary  canal  are  free  to  absorb 
fluid,  and  thus  the  blood  contains  more  watery  constituents,  and  the 
urine  is  abundant.  This  is  a  symptom  deserving  our  attention,  but 
it  is  not  a  certain  one;  several  cases  among  those  illustrative  of 
disease  of  the  sigmoid  flexure  had  scanty  urine  among  their  earlier 
signs,  and  we  shall  find  that  the  amount  of  urine  is  in  inverse  pro- 
portion to  the  quantity  of  fluid  vomited ;  that  if  in  obstructed  colon 
powerful  drastics  have  been  administered,  and  speedy  vomiting  in- 
duced, or  peritonitis  quickly  set  up,  the  urine  will  be  found  to  be 
small  in  quantity ;  if  peritonitis  take  place  the  condition  of  the  abdo- 
minal sympathetic  may  lead  to  cessation  of  secretion  from  the 
kidney  as  well  as  from  other  glands.  The  fluid  character  of  the 
contents  generally  observed  in  the  distended  intestine  above  the 
seat  of  stricture  is  to  be  remarked,  and  is  an  indication  that  no 
remedies  are  needed  in  these  cases  to  render  the  feces  more  watery, 
but  that  the  spasmodic  state  of  the  diseased  bowel,  in  addition  to 
the  mechanical  impediment,  is  the  immediate  cause  of  the  obstruc- 
tion, and  often  prevents  a  drop  of  fluid  or  any  gas  from  passing  the 
stricture. 

State  of  the  rectum, — Dr.  Barlow  has  here  also  brought  his  diag- 
nostic acumen  to  bear  on  the  elucidation  of  the  symptoms  presented. 
He  has  shown  that  in  intestinal  obstruction  suddenly  produced,  the 
rectum  retains  its  natural  power  of  contraction,  and  will  be  found  to 
be  empty ;  if  the  disease  be  of  gradual  formation,  that  it  is  more 
patulous  and  readily  yields  to  injections.  To  a  certain  extent  this 
is  the  case,  but  the  symptom  is  one  upon  which  we  cannot  rely. 
The  intestine  below  the  obstruction  is  generally  contracted,  though 
sometimes  after  the  occurrence  of  the  strangulation  or  other  occlu- 
sion, a  fecal  evacuation  may  take  place,  or  be  removed  after  injec- 
tion from  below  the  seat  of  stricture,  thus  giving  a  delusive  hope  of 
recovery,  or  misleading  in  diagnosis.  Mr.  Charles  H.  Moore  has 
proposed  the  injection  of  fluid  into  the  colon,  as  a  means  of  enabling 
us  to  detect  the  position  of  the  obstruction,  the  extent  of  the  dulness 
on  percussion  in  the  loins  being  carefully  noticed  ;  and  that  in  this 
way  fluid  may  be  forced  into  the  ascending  colon,  and  indicate  that 
the  disease  is  above  that  part. 

The  discharge  of  blood,  or  of  offensive  mucus,  has  been  mentioned 
by  Mr.  Gorham1  as  a  very  frequent  sign  of  intussusception ;  and  it 
may  be  here  remarked  that  it  is  important  in  all  cases  of  this  kind 
to  make  a  careful  manual  examination  of  the  rectum,  as  well  as  of 
all  the  parts  in  which  hernia  may  occur.  By  this  simple  means  im- 
pacted feces,  inflamed  hemorrhoids,  cancer  of  the  rectum,  prolapsus 
ani,  suppuration  in  the  pelvis,  each  of  which  may  lead  to  symptoms 
of  insuperable  constipation,  may  be  diagnosed. 

1  '  Guy's  Hospital  Reports.' 


INTERNAL    STRANGULATION.  429 

In  internal  strangulation  there  may  be  no  excitement  of  pulse  nor 
any  febrile  disturbance ;  the  patient  may  be  free  from  distress  ex- 
cept that  the  abdomen  is  distended,  and  the  bowels  do  not  act  •'  the 
mind  may  be  perfectly  clear,  but  there  is  generally  some  anxiety  of 
expression;  day  after  day  may  pass  in  this  way,  till  prostration, 
with  hiccough  and  peritonitis  supervened.  We  often  find  that  the 
bowels  act  when  sphacelus  of  the  strangulated  intestine  takes  place; 
the  friends  of  the  patient  suppose  that  the  urgent  symptom,  consti- 
pation, being  relieved,  all  will  be  well ;  the  bowels  may  act  copiously, 
but  on  examination  the  patient  may  be  cold  and  nearly  pulseless ; 
he  is  in  a  dying  state,  although  the  mind  is  clear  and  perfectly  con- 
scious. The  period  at  which  a  fatal  result  ensues  is  liable  to  great 
variation.  In  sudden  strangulation  of  the  small  intestine  we  some- 
times find  that  death  takes  place  in  five  to  seven  days ;  whilst  in 
other  cases,  especially  in  obstruction  of  the  colon,  several  weeks  may 
elapse,  and  the  patient  may  remain  free  from  pain  and  distress  till 
about  forty-eight  hours  before  death.  Cases,  however,  recover 
when  the  patient  has  been  apparently  in  a  hopeless  state ;  the  bowels 
act,  the  tympanitis  subsides,  and  the  strength  soon  returns;  some- 
times, however,  after  the  development  of  favorable  symptoms,  a  re- 
lapse takes  place,  and  the  obstruction  leads  to  a  fatal  result. 

Intussusception  is  that  condition  in  which  one  portion  of  the  intes- 
tine passes  into  another,  as  the  finger  of  a  glove  drawn  within  itself. 
In  this  state  there  need  not  necessarily  be  entire  obstruction,  unless 
congestion,  effusion,  and  inflammation  close  the  canal  completely. 
The  section  presents  us  with  three  layers  of  intestine ;  two  mucous 
and  two  serous  surfaces  being  opposed  to'  each  other,  and  in  the 
centre  are  placed  the  ordinary  mucous  surfaces.  It  is  said  that  there 
is  sometimes  a  second  involution  of  the  intestine  from  below,  passing 
in  an  opposite  direction  ;  or  that  the  only  involution  may  be  from 
below  upwards.  The  occurrence  of  such  a  condition  must  be  very 
rare,  and  obstruction  from  it  still  more  so.  The  mesentery  attached 
to  the  involuted  portion  is  also  drawn  in,  and  by  its  traction  the 
central  portion  of  intestine  becomes  somewhat  curved  laterally,  and 
the  opening  of  the  most  depending  part  is  observed  to  be  linear. 
The  vessels  of  the  portion  of  intestine  thus  incarcerated  become  en- 
gorged, and  may  render  the  obstruction  complete ;  the  whole  of  the 
folds  involved  become  swollen  and  deeply  congested,  and  blood  is 
extravasated  into  the  substance  of  the  mucous  membrane,  as  well  as 
into  the  mesentery ;  in  a  short  time  both  the  serous  and  the  mucous 
surfaces  become  inflamed,  and  an  effusion  of  lymph  takes  place ;  the 
opposed  serous  surfaces  become  adherent,  and  so  to  a  less  degree  the 
mucous  surfaces ;  bloody  serum  and  mucus  are  effused  into  the  canal, 
and  this  discharge  per  rectum  is  a  diagnostic  sign  of  intussusception. 
If  life  be  prolonged,  and  the  intussusception  continue,  the  serous 
surfaces  at  the  opening  or  upper  part  are  rendered  adherent ;  the 
contained  intestine  becomes  gangrenous,  and  is  often  detached  as  a 
slough.  In  this  way  many  inches  of  intestine  may  be  discharged 
per  rectum ;  in  one  instance  as  much  as  forty-four  inches  of  large 
intestine  were  evacuated ;  in  another,  which  terminated  favorably, 


430  INTERNAL    STRANGULATION. 

and  the  specimen  of  which  is  in  the  museum  at  Guy's,  the  whole  of 
the  caecum  and  ascending  colon  were  thus  passed.  If  the  adhesions 
be  disturbed  or  broken  down  after  the  slough  has  separated,  fecal 
abscess  may  be  the  result.  In  some  instances  the  intussusception  is 
restored;  more  frequently,  more  and  more  intestine  is  forced  in, 
symptoms  of  internal  strangulation  supervene,  and  death  results  from 
perforation  into  the  peritoneum,  or  from  peritonitis  set  up  by  the 
direct  extension  of  disease  from  the  strangulated  part.  It  must  not, 
however,  be  supposed  that  the  passage  is  always  occluded  ;  such  is 
sometimes  not  the  case,  and  even  diarrhoea  may  be  produced.  It 
would  seem  that  the  intestine  maybe  thus  incarcerated  within  another 
fold,  without  being  strangulated.  The  case  recorded  by  Dr.  Hughes, 
in  the  Guy's  Reports,  was  of  this  kind  ;  so  also  those  of  Mr.  Phillips 
in  the  'Medical  Gazette;'  and  still  more  remarkably  a  specimen 
exhibited  by  Mr.  Hutchinson  at  the  Pathological  Society,  in  which 
the  symptoms  extended  over  seven  months. 

The  position  of  intussusception  may  be  solely  in  the  small  intes- 
tine, but  more  frequently  a  portion  of  ileum  passes  into  the  caecum 
at  the  valve,  the  valve  being  pushed  onward  and  forming  the  most 
dependent  part ;  and  lastly,  the  intussusception  may  consist  only  of 
one  portion  of  colon  within  another ;  the  cascurn  and  ascending  colon 
may  become  so  involuted  as  even  to  reach  the  rectum.  It  would 
appear  that  in  intussusception  in  the  colon,  constipation  is  less  con- 
stant as  a  sign  of  disease. 

According  to  the  following  tables  from  Dr.  Brinton's  Croonian 
Lectures,  recorded  in  the  '  Lancet,'  1859,  it  would  seem  that  ileo- 
caecal  intussusception  is  the  most  frequent  variety ;  this  may  be  the 
case,  if  we  exclude  the  numerous  instances  of  intussusception  which 
take  place  during  the  time  the  patient  is  in  articulo  mortis. 

Intestinal  Obstructions  (excluding  Hernia). 

Frequency,  1  in  280  deaths  (from  12,000  promiscuous  necropsies). 

Intussusception  .  .  .  .  .  .  .43 

External  (bands,  &c.)  .  .  .  .  .  .32 

Parietal  (Strictures,  &c.)         .  .  .  .  .  .17 

Torsions  .  .  .  .  .  ..  .  .8 

100 

Varieties,  relative  frequency  per  cent,  (from  600  necropsies  of  obstruction). 
Intussusception,  varieties  of,  per  cent. — 

Ileo-caecal         .  .  .  .  .  .  .  .56 

Ileac      .  .  .  .  .  .  .  .  .28 

Jejunal  ........       4 

Colic     .  .  .  .  .  .  .  .  .12 

100 

In  nearly  8000  post-mortem  records  at  Guy's  Hospital,  there  are 
17  cases  of  fatal  invagination.  Ileo-cagcal  10,  ileac  5,  rectal  2,  one 
of  these  due  to  villous  growth. 

The  number  of  intussuscepted  portions  also  varies  much,  being 
sometimes  single,  but  in  young  persons,  and  especially  infants,  it  is 
exceedingly  common  to  find  numerous  parts  so  aflected,  from  six  to 


CANCEROUS    DISEASE.  431 

twelve,  or  even  more.  Some  of  these,  however,  are  probably  pro- 
duced immediately  before  death  ;  there  is  absence  of  all  symptoms 
of  strangulation,  and  in  the  intestine  itself  neither  congestion,  effu- 
sion, nor  ulceration  exist ;  they  are  most  frequently  observed  in 
inflammatory  disease  of  the  brain,  and  hydrocephalus. 

The  symptoms  of  intussusception  are  those  of  colic  with  constipa- 
tion; sudden  local  pain  is  produced  in  the  bowels,  followed  by 
vomiting,  constipation,  prostration,  haggard  expression  of  counte- 
nance, failing  pulse,  distension  of  the  abdomen,  stercoraceous  vomit- 
ing, peritonitis,  and  death.  It  is  exceedingly  difficult  to  distinguish 
this  condition  from  ileus  arising  from  internal  strangulation  and 
local  enteritis ;  but  after  a  time  there  may  be  discharge  of  blood  and 
mucus  from  the  involuted  portion,  which  materially  assists  in  form- 
ing a  correct  diagnosis.  In  intussusception,  a  firm  mass  may  often  be 
felt  at  the  seat  of  pain,  which  is  not  the  case  in  ordinary  internal 
strangulation.  In  intussusception  of  the  small  intestine  the  tumor 
may  be  central,  whilst  in  ileo-colic  and  colic  involution  the  mass  will 
be  in  the  course  and  position  of  the  colon.  The  sudden  onset  of  the 
pain,  its  subsidence  and  paroxysmal  aggravation  are  indications  of 
this  form  of  obstruction.  It  has  been  before  mentioned  that  diar- 
rhoea sometimes  supervenes,  especially  where  the  large  intestine  is 
affected ;  and  it  is  occasionally  noticed  where  the  disease  is  of  a 
chronic  character.  In  seeking  to  arrive  at  a  correct  diagnosis,'  it  is 
well  always  to  examine  the  rectum. 

The  cause  of  this  abnormal  involution  appears  to  be  sudden  and 
spasmodic  contraction  of  a  portion  of  intestine,  impelled  onwards 
into  a  part  which  is  less  contracted  or  altogether  flaccid.  It  occurs 
at  all  periods  of  life,  but  it  is  much  more  frequent  in  youth  and 
infancy. 

The  prognosis,  although  very  unfavorable  when  we  have  well- 
marked  indications  of  the  existence  of  intussusception,  is  not  without 
hope,  and  we  have  seen  almost  hopeless  cases  recover.  In  some  the 
intestine  is  restored  to  its  normal  state ;  in  others,  the  strangulated 
bowel  sloughs  off',  the  canal  becomes  free,  and  the  divided  intestine 
unites. 

Cancerous  Disease  of  the  Intestine. — Cancer  of  the  stomach  is  a 
disease  of  frequent  occurrence j  but  cancer  is  more  rare  in  other 
portions  of  the  alimentary  canal.  We  have  Already  described  in- 
stances of  it  as  affecting  the  duodenum  and  the  caecum,  and  other 
portions  of  the  small  intestine  and  of  the  colon  are  occasionally  thus 
diseased;  still  the  rectum  and  the  sigmoid  flexure  of  the  colon  are 
the  parts  of  the  intestine  most  frequently  affected,  and  it  is  to  the 
latter,  that  we  direct  especial  attention  as  a  seat  of  obstruction. 

The  termination  of  the  sigmoid  flexure  appears  to  be  particularly 
prone  to  this  form  of  disease,  and  many  of  those  cases  which  are 
described  as  cancer  of  the  upper  third  of  the  rectum  are  at  this  part, 
and  have  been  pushed  down  into  the  pelvis  by  the  obstruction  pro- 
duced. It  is  a  peculiar  form  of  disease  that  we  find  thus  developed; 
not  the  extensive  deposit  with  glandular  infiltration,  though  this  is 
sometimes  the  case,  but  a  modification  of  scirrhus.  There  is  a  growth 


432  CANCEROUS    DISEASE. 

from  the  mucous  membrane,  the  muscular  fibre  is  infiltrated  and 
contracted,  and  the  calibre  of  the  intestine  is  diminished.  The  glands 
are  frequently  not  at  all  affected,  and  in  this  respect  it  closely  re- 
sembles epithelial  cancer.  The  constriction  of  and  growth  in  the 
intestine  are  sometimes  circular,  sometimes  one  side  is  much  more 
affected  than  the  other.  On  examining  the  condensed  part  we  find 
fibrous  tissue,  and  some  elongated  nuclei;  but  the  growth  from  the 
mucous  membrane  presents  more  of  the  elements  of  cancer.  These, 
however,  are  not  like  the  ordinary  epithelial  cancer  elements,  but 
many  of  the  cells  are  large  columnar  epithelium,  with  a  large  nucleus, 
the  growth  being  modified  on  account  of  its  situation  on  a  columnar 
epithelial  surface,  an  instance  of  the  differentiation  of  abnormal 
growth. 

Medullary  and  colloid  cancer  sometimes  affect  this  part,  so  also 
lymphoma  and  adenoma,  but  their  course  is  different  from  that  of 
scirrhous  disease.  In  medullary  cancer  the  ulcerative  process  ex- 
tends through  the  coats  of  the  intestine  more  rapidly,  and  instead  of 
intestinal  obstruction  we  have  fecal  abscess,  either  in  the  iliac  fossa, 
or  within  the  abdominal  cavity  itself,  or  a  communication  may  take 
place  with  the  bladder.  In  the  rectum  similar  forms  of  disease  are 
presented,  which  occur  in  its  several  parts :  and  scirrhus  of  this  part 
leads  to  contraction,  thickening  of  the  external  tissues,  and  obstruc- 
tion of  the  intestinal  canal.  Medullary  cancer,  on  the  contrary 
causes  ulceration  and  communication  with  the  other  pelvic  viscera, 
with  the  vagina,  bladder,  or  uterus,  so  that  all  the  viscera  become 
matted  together  into  one  mass.  The  rectum  also  frequently  becomes 
involved,  by  the  extension  of  disease  from  the  uterus  and  vagina, 
leading  to  terrible  manifestations  of  disease  and  suffering.  Epithelial 
growths  of  a  cancerous  character  arise  from  the  mucous  membrane 
of  the  rectum,  as  well  as  from  the  sigmoid  flexure,  and  they  lead 
slowly  to  obstruction  or  to  exhausting  diarrhoea. 

Where  the  coats  of  the  intestine  are  thus  diseased,  the  intestine 
above  the  stricture  becomes  gradually  distended,  the  mucous  coat  is 
thickened,  and  the  muscular  hypertrophied,  so  as  to  be  in  some  cases 
a  quarter  of  an  inch  in  thickness.  The  extent  of  these  changes  varies 
much,  and  in  chronic  and  slowly  progressive  disease  they  are  more 
manifest.  The  distension  of  the  intestine  also  produces  inflammation 
and  ulceration  of  the  mucous  membrane  above  the  stricture,  and  it 
leads  in  many  cases  to  perforation;  this  condition  of  ulcerative  ero- 
sion is  sometimes  very  extensive,  at  a  considerable  distance  from  the 
seat  of  obstruction ;  thus  we  find  perforation  of  the  caecum  taking 
place  in  obstruction  of  the  sigrnoid  flexure. 

Cancerous  disease  of  the  ascending  or  transverse  colon  takes  place 
more  rarely,  and  appears  to  be  produced  by  some  local  exciting 
cause,  as  the  cicatrix  of  an  ulcer,  or  by  a  blow ;  still  it  is  far  from 
infrequent.  In  a  case  of  colloid  cancer  of  the  stomach  we  observed 
a  similar  state  of  the  ascending  colon,  but  in  a  less  advanced  con- 
dition. 

Mr.  Birkett,  in  the  'Pathological  Transactions,'  has  recorded  a 
remarkable  case  of  vascular  villous  growth  from  the  colon  near  the 


CANCEROUS    DISEASE. 


433 


liver;  the  growth  was  covered  with  epithelium,  and  its  cancerous 
character  was  very  doubtful.  It  was  taken  from  a  man,  aged  fifty  - 
eight,  who  a  year  before  his  death  had  had  pain  in  the  abdomen 
and  diarrhoea.  Two  months  before  admission  into  Guy's,  he  had 
had  constipation  and  pain,  and  when  brought  to  the  hospital  he  had 
symptoms  resembling  strangulated  hernia,  with  constipation  of  one 
week's  duration ;  he  had  had  a  scrotal  hernia,  and  the  sac  still 
remained.  The  caecum  could  be  seen  distended,  and  so  also  the 
ascending  colon,  as  far  as  the  liver,  where  there  was  pain  on  pres- 
sure ;  the  descending  colon  could  not  be  felt.  Mr.  Birkett  explored 
the  hernial  tumor,  but  no  intestine  was  within  it.  The  propriety  of 
opening  the  ascending  colon  was  discusssed ;  but  the  patient  died 
four  days  after  admission.  (See  Prep,  in  Guy's  Museum,  185465.)  In 
another  instance  a  blow  on  the  hypochondrium  was  followed  by  a 
cancerous  growth,  which  led  to  fecal  abscess  and  to  perforation  of 
the  jejunum. 

Carcinoma  of  the  stomach  sometimes  extends  to  the  transverse 
colon;  such  was  the  case  in  one  of  the  instances  we  have  recorded 
of  disease  of  the  stomach ;  but  although  there  was  fecal  eructation, 
no  stercoraceous  vomiting  occurred.  Drs.  Gairdner  and  Murchison 
have  shown  the  important  diagnostic  indications  of  this  symptom  in 
communication  between  the  stomach  and  intestine.1  It  is  more 
common  to  find  disease  of  the  colon  extending  into  the  stomach 
than  the  reverse,  namely,  disease  of  the  stomach  into  the  colon. 

The  ileum  and  jejunum  are  very  rarely  affected  with  primary 
scirrhous  and  medullary  cancer;  they  are  sometimes  involved  in 
cancer  of  the  mesenteric  glands;  but  we  have  never  observed  in- 
superable obstruction  thus  produced. 

During  the  last  16  years  45  cases  of  stricture  of  the  intestine  have 
occurred  at  Guy's,  as  shown  by  the  post-mortem  records: 


General  narrowing  from  disease  of  the  peritoneum 

extending  into  the  coats  of  the  bowel 
Of  the  small  intestine 

caecum  and  ascending  colon 

hepatic  flexure 

transverse  colon 

splenic  flexure 

descending  colon 

sigmoid  flexure 

rectum 


2 

1 

2 

3 

2 

1 

4 

10 

20 

45 


Symptoms. — In  scirrhous  disease  of  the  sigmoid  flexure,  if  we  pos- 
sess a  history  of  all  the  symptoms,  the  nature  of  the  malady  may 
often  be  correctly  shown.  There  is  slight  pain,  fixed  in  character, 
and  remaining  for  a  variable  period,  in  the  left  iliac  fossa,  with  con- 
stipation, or  an  irregular  condition  of  the  bowels:  after  one  or  two 
attacks  of  this  kind,  with  several  months  or  years  between  them, 
the  constriction  becomes  narrowed  to  such  an  extent  that  a  very 
slight  increase  renders  it  complete.  The  bowels  again  are  confined, 


28 


'  Edinburgh  Monthly  Journal.' 


434  CANCEROUS    DISEASE. 

the  patient  feels  uncomfortable  from  their  loaded  condition;  the 
abdomen  is  gradually  distended,  vomiting  coines  on,  and  the  symp- 
toms of  insuperable  obstruction  follow.  The  vomiting  occurs  mur.h 
later  than  in  obstruction  of  the  small  intestine,  unless  powerful 
drastic  purgatives  have  been  administered;  the  secretion  of  the 
urine  continues  free,  and  the  patient  may  appear  in  comfortable 
health,  except  that  the  bowels  have  not  acted.  After  ten  or  twelve 
days,  however,  if  no  evacuation  ensue,  the  colon  becomes  much  en- 
larged, its  distended  coils  can  be  seen  through  the  parietes,  and 
there  is  tympanitis  in  both  lumbar  regions;  the  urgent  peristaltic 
movements  may  be  detected  through  the  parietes;  at  last  ulceration 
takes  place  above  the  seat  of  stricture,  and  leads  to  fatal  peritonitis 
and  extravasation,  or  peritonitis  arises  from  the  enormous  distension, 
and  the  more  general  inflammation  of  the  coats  of  the  intestine. 
Sometimes,  with  judicious  treatment,  after  symptoms  of  threatening 
peritonitis,  the  bowels  are  acted  upon,  and  the  patient  is  for  a  short 
time  spared;  even  diarrhoea  will  occasionally  supervene;  the  patient 
then  continues  much  enfeebled,  and  after  a  few  months  sinks  ex- 
hausted, or  another  attack  of  constipation  terminates  fatally. 

The  same  symptoms  of  insuperable  obstruction  sometimes  arise  in 
medullary  and  colloid  cancer ;  but,  as  before  stated,  they  less  fre- 
quently terminate  in  complete  occlusion.  The  intestines  become 
united  together,  ulceration  extends  through  the  coats,  local  peritoni- 
tis and  fecal  abscess  are  the  result,  with  severe  pain  and  hectic  fever, 
or  the  cancerous  ulceration  may  extend  into  the  iliac  fossa  and  sup- 
puration may  burrow  down  beneath  Poupart's  ligament,  as  in  dis- 
ease of  the  caecum,  or  the  disease  may  form  a  communication  with 
the  bladder. 

There  is  much  less  pain  in  cancerous  disease  of  the  sigmoid  flex- 
ure than  of  the  rectum,  because  the  parts  are  more  free,  there  is  less 
pressure  on  the  nerves,  and  the  adjoining  structures  are  less  involved. 
If  the  rectum  be  affected,  the  constipation  and  difficulty  of  defecation 
is  more  constant;  the  pain  produced  is  often  intense,  especially  where 
the  lower  third  is  affected.  The  feces  become  flattened  ;  this  may  be 
the  case  when  the  sigmoid  flexure  is  the  part  diseased,  but  it  is  less 
liable  to  occur,  for  the  feces  can  be  retained  for  a  sufficient  period  in 
the  rectum  to  reassurne  their  ordinary  character.  In  the  later  stages 
of  cancerous  disease  of  the  rectum,  and  in  the  fibro-cellular  thickening 
and  contraction  of  its  coats,  diarrhoea  instead  of  constipation  may 
occur ;  I  have  seen  several  such  instances,  and  Nelaton  refers  to  this 
liquid  condition  of  feces  and  their  free  separation  as  not  unfrequent 
in  syphilitic  disease.  Tactile  examination  may  detect  disease  at  the 
lower  part  of  the  rectum,  but  not  at  its  upper  third.  The  extension 
of  disease  to  the  bladder,  vagina,  and  uterus,  leads  to  most  distress- 
ing complications,  and  special  symptoms  are  produced.  In  obstruc- 
tion of  the  alimentary  canal  as  we  have  before  said,  the  rectum  should 
always  be  examined. 

The  symptoms  of  cancerous  disease  of  the  ascending  or  transverse 
colon  are  of  the  same  kind  as  we  have  just  described,  but  it  is  more 
easy  to  detect  a  hardness  or  tumor  produced  by  the  growth  in  the 


CANCEROUS    DISEASE.  435 

intestine.  In  many  instances  there  is  severe  pain  at  the  seat  of  the 
obstruction  at  an  early  stage,  and  this  pain  I  have  in  several  in- 
stances noticed  as  being  produced  as  soon  as  fluids  have  been  taken; 
diarrhoea  is  sometimes  present,  or  it  alternates  with  constipation. 
Again,  we  do  not  find  that  the  transverse  colon  becomes  distended 
and  tympanitic  across  the  abdomen;  nor  that  there  is  the  same  reso- 
nance in  the  left  lumbar  region.  These  indications,  however,  must 
be  used  with  great  caution,  because  the  distension  of  the  small  intes- 
tine may  lead  to  the  presence  of  enormous  coils,  which  may  easily 
be  mistaken  for  an  enlarged  colon.  The  suggestion  of  Mr.  Moore 
may  be  tried,  namely,  the  injection  of  water  into  the  colon  and  the 
examination  of  the  amount  of  dulness  produced.  The  intestine,  how- 
ever, in  some  cases,  becomes  so  contracted  below  the  seat  of  stricture, 
as  not  readily  to  yield  to  the  injection  of  water,  and  we  might  be  led 
to  a  very  incorrect  diagnosis  if  we  trusted  to  this  means  alone. 

In  many  patients  who  are,  affected  with  cancerous  obstruction  of 
the  sigmoid  flexure,  there  is  but  little  emaciation  or  appearance  of 
cancerous  cachexia.  They  may  be  well  nourished,  and  apparently 
in  health  ;  generally,  however,  there  has  been  some  indication  of  dis- 
ease, as  shown  by  troublesome  constipation,  an  occasional  fixed 
pain,  and  sometimes  by  a  discharge  of  mucus  from  the  rectum. 

These  forms  of  scirrhous  cancerous  disease  rarely  occur  in  early 
life;  at  that  period  it  is  more  likely  to  be  medullary  or  lyrnphadeuo- 
matous  in  character;  but  there  are  exceptional  instances  in  this 
respect. 

The  position  at  which  the  sigmoid  flexure  becomes  affected  is  at 
the  brim  of  the  pelvis,  where  it  is  -more  liable  to  temporary  com- 
pression. It  is  also  at  that  part  where  the  triple  longitudinal  mus- 
cular band  assumes  a  continuous  character  around  the  intestine. 

Diai/nosix. — In  our  remarks  on  internal  strangulation,  we  have 
already  pointed  out  the  diagnostic  value  of  many  of  the  symptoms 
presented.  The  varied  causes  of  obstruction  must  be  also  borne  in 
mind ;  comprising  not  only  the  forms  of  internal  strangulation,  of 
intussusception,  and  of  cancerous  disease,  but  the  presence  of  tumors, 
of  enteritis  or  peritonitis,  the  impaction  of  feces  or  of  foreign  bodies, 
tumors  connected  with  the  uterus  or  ovaries,  and  hemorrhoidal 
tumors.  In  intussusception  there  is  generally  more  pain  resembling 
colic,  there  is  the  discharge  of  bloody  mucus,  and  a  tumor  can  fre- 
quently be  felt  at  the  affected  part:  and  in  not  a  few  cases  the  in- 
volved bowel  may  be  detected  by  examination  per  rectum.  In 
internal  strangulation  the  vomiting  is  more  severe,  the  onset  more 
sudden  than  in  cancerous  disease,  and  frequently  something  has  been 
felt  to  have  given  way  or  slipped;  there  is  a  great  resemblance  to 
the  symptoms  of  ordinary  hernia;  the  small  intestine  is  the  part  that 
is  generally  thus  strangulated;  and  then,  whilst  the  vomiting  is 
more  early  and  severe,  the  abdomen  is  less  distended,  and  the  course 
of  the  colon  cannot  be  so  easily  traced.  In  impacted  feces  alone, 
unless  some  foreign  body  be  also  present,  the  symptoms  rarely,  if 
ever,  become  so  urgent,  and  are  scarcely  ever  fatal.  In  speaking  of 
constipation,  we  have  quoted  a  case  from  the  '  Medical  Ga/stte,' 


436  TREATMENT    OF    INTERNAL    OBSTRUCTION. 

where  after  seven  months  of  fecal  obstruction,  the  patient  had  a  fall, 
and  peritonitis  was  produced ;  she  had  had  attacks  of  constipation 
of  two  months'  duration,  for  four  years.  In  simple  fecal  retention, 
after  a  whole  month  has  elapsed,  we  may  find  very  little  discomfort, 
and  the  distension  not  extreme  in  degree.  In  cancerous  disease  of  the 
sigmoid  flexure,  the  gradual  character  of  the  obstruction,  the  seat  of 
pain,  the  distension  of  the  abdomen  without  tenderness,  the  abund- 
ance of  urine,  the  late  period  at  which  vomiting  occurs,  are  the 
principal  signs;  and  many  of  these  cases  closely  resemble  simple 
fecal  impaction.  In  the  one  we  shall  probably  find  that  injections 
per  rectum  will  be  effective,  and  after  a  time  they  will  be  followed 
by  relief:  in  the  other,  the  injection  will  in  a  short  time  be  returned, 
only  a  small  quantity  can  be  thrown  up,  and  no  fecal  contents  are 
evacuated. 

The  early  tenderness  of  the  abdomen  distinguishes  enteritis  and 
peritonitis  in  most  cases ;  and  recto-vaginal  examination  serves  to 
remove  other  sources  of  diagnostic  difficulty. 

Treatment. — If  after  the  administration  of  mild  aperient  medicines, 
or  even  without  their  use,  it  has  been  ascertained  with  tolerable 
certainty,  that  constipation  from  one  or  other  of  the  causes  we  have 
described  exists,  it  is  exceedingly  unwise  to  employ  active  treatment. 
Purgatives  of  all  kinds  are  better  avoided,  and  the  use  of  drastic 
measures  will  tend  to  aggravate  the  sufferings,  to  shorten  life,  and 
to  remove  the  possible  chances  of  recovery. 

The  administration  of  opium  is  now  known  to  be  attended  with, 
beneficial  results,  and  frequently  with  partial,  if  not  with  permanent 
relief.  By  this  means  the  peristaltic  action  is  checked,  spasmodic 
contraction  diminished,  and  the  opening  which  previously  would  not 
allow  the  passage  of  flatus,  will  suffer  fluid  feces  to  escape.  Solid 
opium  may  be  given,  as  in  the  soap  and  opium  pill.  Some  combine 
calomel  with  the  opium,  but  we  prefer  opium  alone,  for  the  mercurial 
medicine  increases  depression  ;  it  probably  hastens  perforation,  and 
extravasation  is  less  likely  to  be  limited  by  adhesion  after  its  action. 

Drastic  purgatives,  as  colocynth,  croton  oil,  scammony,  mercurials, 
&c.,  stimulate  and  excite  the  intestine  to  greater  contraction  ;  vomit- 
ing of  a  stercoraceous  character  is  set  up  more  quickly  or  is  increased, 
and  ulceration  or  fatal  peritonitis  is  speedily  produced.  Electricity, 
which  is  a  valuable  remedy  in  simple  constipation,  is  here  produc- 
tive of  injury  to  the  patient. 

If  there  be  any  indication  of  local  peritonitis,  leeches  should  be 
applied,  and  rest  in  the  recumbent  posture  enjoined.  The  diet  should 
be  spare,  and  of  a  fluid,  unirritating,  and  non-stimulating  kind.  If, 
however,  we  find  great  prostration,  it  is  well  to  give  brandy  or  wine, 
when  they  can  be  taken. 

Enemata  are  of  great  value  in  removing  fecal  concretions  from  the 
rectum,  and  below  the  seat  of  the  stricture ;  and  are  sometimes 
followed  by  the  discharge  of  flatus,  affording  great  relief  to  the 
patient.  In  this  way  warm  water,  soap,  castor  oil,  or  turpentine  in- 
jections may  be  used ;  and  several  ounces  of  simple  olive  or  linseed 
oil  thus  thrown  into  the  rectum  sometimes  afford  considerable  relief. 


TREATMENT    OF    INTERNAL    OBSTRUCTION.  437 

Injections  of  this  kind  are  most  effectually  administered  by  means 
of  an  O'Beirne's  long  tube  ;  care,  however,  must  be  used  lest  the  ex- 
tremity of  the  tube  turn  upon  itself.  The  simple  introduction  of  an 
enema  tube,  and  its  retention  for  a  short  time,  may  excite  the  lower 
bowel  to  contract,  and  cause  the  expulsion  of  flatus,  thus  relieving 
the  painful  distension.  In  some  instances,  it  is  well  to  use  nutrient 
enemata,  which  may  serve  to  prolong  the  exhausted  powers  of  life 
for  a  short  period.  Great  care  is  necessary  in  the  use  of  the  long 
tube;  we  have  known  perforation,  abrasion  of  the  intestine,  and 
fatal  peritonitis  induced  by  it,  and  in  one  instance  emphysema.  The 
mucous  membrane  of  the  bowel  is  softened  and  the  parts  adherent; 
in  the  case  in  which  emphysema  was  produced  the  patient  passed 
the  enema  tube  through  an  ulcer  into  the  cellular  tissue. 

By  the  use  of  these  means,  when  the  patient  is  almost  in  extremis, 
an  evacuation  may  be  passed,  and  recovery  take  place.  In  some 
cases,  after  the  continued  use  of  opium,  diarrhoaa  is  produced  and 
may  become  so  severe  as  to  require  remedial  measures. 

Change  of  position  has  in  some  instances  appeared  to  produce 
benefit,  and  has  been  followed  by  recovery ;  but  whilst  this  may 
sometimes  occur,  we  have  witnessed  the  injurious  effect  of  moving 
the  patient  when  the  peritoneum  is  intensely  congested,  and  per- 
haps inflamed  from  the  great  distension :  death  has  in  several  in- 
stances quickly  followed. 

The  application  of  cold  water,  of  ice,  or  the  exposure  of  the  sur- 
face of  the  abdomen  to  the  air,  has  been  sometimes  advantageously 
tried.  In  one  of  the  cases  which  I  have  narrated,  the  patient  said, 
whilst  the  abdomen  was  exposed,  that  he  felt  that  something  had 
slipped,  and  in  a  short  time  an  abundant  fecal  evacuation  was  passed, 
and  recovery  took  place.  In  another  case  obstruction  had  gone  on 
for  many  days,  the  mischief  appeared  to  be  in  the  small  intestine, 
so  that  colotomy  could  not  be  performed,  and  a  fatal  result  was 
anticipated,  when  the  application  of  a  bag  of  ice  to  the  abdomen 
was  followed  by  free  action  of  the  bowels.  The  patient,  a  woman 
of  middle  age,  left  the  hospital  comparatively  well. 

In  the  absence  of  relief  by  these  means,  the  question  of  surgical 
interference  becomes  one  of  anxious  consideration ;  after  death  from 
internal  strangulation,  the  obstruction  has  been  found  so  simple  in 
character,  that  with  great  facility  it  might  have  been  divided,  and 
perhaps  the  life  saved.  In  several  instances,  Mr.  Hilton  attempted 
this  mode  of  relief,  with  an  amount  of  success  which  subsequent 
operators  have  confirmed;  but  it  must  be  borne  in  mind,  first,  that 
the  peritoneum  is  already  inflamed,  or  in  a  state  of  intense  conges- 
tion, and  that  general  peritonitis  is  very  likely  to  follow  ;  secondly, 
that  there  is  great  difficulty  in  the  diagnosis,  and  that  some  recover 
from  apparently  a  dying  condition.  A  very  interesting  communica- 
tion on  this  subject  was  read  at  the  Hunterian  Society,  by  Mr. 
Hutchinson,  to  which  we  must  refer,  and  to  the  papers  of  Mr.  Hil- 
ton, in  the  Guy's  Reports  of  1852.  The  operation  of  opening  the 
colon  in  the  loin  has  in  many  cases  prolonged  life ;  it  has  been  espe- 
cially performed  in  cancerous  disease  of  the  rectum,  to  relieve  either 


438  TREATMENT    OF    INTERNAL    OBSTRUCTION. 

the  obstruction  or  the  severity  of  the  pain,  and  in  other  cases,  where 
we  have  indications  of  obstruction  in  the  sigmoid  flexure,  it  may  be 
employed  with  much  success.  In  the  case  recorded  by  Mr.  Hilton, 
in  the  paper  just  referred  to,  the  relief  was  exceedingly  marked, 
and  the  life  of  the  patient  prolonged  for  several  months ;  of  late 
years  numerous  successful  cases  have  been  recorded  by  Curling, 
Bryant,  Maunder,  and  others.  In  many  instances  I  have  witnessed 
the  value  of  this  operation  ;  sometimes  for  the  relief  of  ulceration  of 
the  colon  extending  into  the  bladder;  in  one,  several  years  ago,  the 
patient  was  reduced  to  extreme  emaciation  and  distress  from  the 
presence  of  feces  in  the  bladder.  Mr.  Bryant  opened  the  colon,  the 
patient  regained  strength,  and  the  opening  in  the  loins  is  of  only 
slight  discomfort  to  him.  In  another  case,  cancerous  disease  of  the 
bowel  led  to  the  same  distressing  complication,  colotomy  relieved 
the  suffering  and  prolonged  life  for  several  months.  Last  year  a 
patient,  aged  54.  consulted  me  for  dyspeptic  symptoms  on  January 
24th  ;  organic  disease  was  suspected  ;  he  had  become  thinner,  suf- 
fered from  pain  after  food,  and  flatulence,  sometimes  from  vomiting, 
the  bowels  were  inactive.  On  March  4th  the  bowels  had  not  acted 
for  a  fortnight,  there  was  great  distension  ;  the  coils  of  the  intestine 
were  visible,  and  peristaltic  movement  was  distinct ;  there  was 
vomiting,  but  no  pain.  Opium  with  belladonna  was  given,  and 
injections  of  oil,  and  afterwards  of  soap  and  water  were  used.  Colo- 
tomy was  recommended  if  the  bowels  did  not  act.  He  was  brought 
to  Guy's  on  March  13th,  the  bowels  acted  freely  after  admission,  but 
still  the  abdomen  remained  distended.  Remedies  were  used  to  re- 
lieve this  flatulent  distension,  but  the  bowels  again  became  confined, 
and  it  was  evident  that  the  danger  was  imminent;  a  fatal  result  was 
feared,  when  Mr.  Davies  Colley,  on  April  6th,  performed  colotomy. 
The  urgent  symptoms  were  relieved,  and  after  a  few  days  feces 
were  passed  by  the  rectum,  and  the  patient  left  the  hospital  com- 
paratively well  on  May  5th.  In  a  valuable  paper  by  Mr.  Caesar 
Hawkins,  in  the  '  Transactions  of  the  Royal  Medical  and  Chirurgi- 
cal  Society,'  the  result  of  the  operation  of  colotomy  in  forty-four 
cases  of  stricture  of  the  colon  or  rectum  is  recorded;  in  ten  cases 
death  took  place  withiu  forty-eight  hours,  in  twenty-one  within  five 
weeks,  and  thirteen  recovered ;  of  these  six  died  in  six  months,  and 
nine  survived  more  than  one  year. 

The  colon  in  its  ascending  or  descending  part  may  be  opened  in 
many  cases  with  facility,  without  dividing  the  peritoneum.  Mr. 
Maunder  has  proposed  opening  the  small  intestine  through  the  peri- 
toneum, and  has  successfully  performed  such  an  operation.  My  col- 
league, Mr.  Bryant,  has  also  successfully  performed  similar  opera- 
tions ;  in  one  case  the  patient  survived  eighteen  months.  In  many 
cases,  however,  these  operations  have  been  deferred  so  long,  that 
peritonitis  has  already  arisen  from  the  extreme  distension  and  the 
skill  of  the  surgeon  is  then  placed  under  the  most  disadvantageous 
circumstances. 

In  the  treatment  of  intussusception,  every  possible  means  should  be 
employed  to  quiet  the  propulsive  action  of  the  intestine;  but  much 


INTERNAL    STRANGULATION.  439 

good  may^be  effected  by  local  means.  If  the  bowel  be  felt  in  the 
rectum,  it  may  sometimes  be  returned  by  the  introduction  of  a 
bougie,  or  of  a  candle:  and  in  other  cases  gentle  distension  by  the 
injection  of  warm  water,  or  inflation  by  air,  has  apparently  produced 
a  return  of  the  bowel.  Mr.  Hutchinson  has  suggested  operative  in- 
terference in  these  cases,  by  opening  the  peritoneum  and  withdraw- 
ing the  invaginated  bowel  ('Med.-Chir.  Transactions,'  vol.  Ivii);  in 
other  cases  in  which  the  operation  has  been  performed,  even  in 
recent  cases,  it  has  been  found  that  the  bowel  could  not  be  withdrawn ; 
out  of  eight  cases  two  have  been  successful,  one  under  Mr.  Hutchin- 
son, and  the  other  under  Mr.  Howse,  six  have  proved  fatal. 

CASES   OF   INTERNAL   STRANGULATION. 

CASE  CXLIII.  Internal  Strangulation  of  the  lleum.  Band  of  Adhe- 
sion— Elizabeth  B — ,  set.  52,  was  admitted,  March  10th,  1857,  into  Guy's 
Hospital.  She  was  a  married  woman,  thin,  of  sallow  complexion,  and  had 
had  a  family.  For  twenty  years  she  had  had  occasional  pain  in  the  left  side, 
the  bowels  had  generally  been  confined,  but  she  had  not  had  any  attack  like 
that  for  which  she  was  admitted. 

On  March  oth,  five  days  before  admission,  after  breakfast,  she  experienced 
a  sudden  pain  in  the  abdomen  ;  it  commenced  about  the  navel,  but  soon  ex- 
tended over  the  whole  abdomen  ;  vomiting  came  on  an  hour  afterwards  ;  the 
bowels  had  been  open  slightly  the  same  morning,  but  had  been  confined  on  the 
previous  day.  From  that  time  no  evacuation  took  place,  the  vomiting  con- 
tinued, the  abdomen  became,  tympanitic,  and  moderately  distended,  and  there 
\v;i>  slight  tenderness.  The  pain  in  the  abdomen  cams  on  in  paroxysmal  at- 
tacks, but  was  generally  absent  when  she  remained  quiet ;  the  vomited  mat- 
ters continued  bilious,  and  the  urine  abundant. 

On  March  10th,  the  countenance  was  expressive  of  considerable  distress, 
but  was  calm  and  resigned  ;  the  eyes  were  sunken  ;  the  abdomen  was  slightly 
prominent  in  the  centre,  but  not  laterally ;  it  was  tympanitic,  but  free  from 
tenderness ;  the  pulse  was  sharp,  the  respiration  normal,  and  the  urine  was 
abundant.  Purgatives  had  been  given,  and  enemata  administered,  but  she 
had  vomited  the  former. 

She  was  ordered  calomel  and  opium  of  each  gr.  j  every  six  hours,  a  soap 
injection  to  be  administered,  and  a  linseed  poultice  to  be  applied  to  the  ab- 
domen. 

March  12th. — The  countenance  was  more  haggard,  and  the  eyes  more 
sunken  ;  the  vomited  matters  were  thick,  green,  and  offensive,  but  not  ster- 
coraceous  ;  the  pulse  was  more  compressible  ;  the  abdomen  was  in  the  same 
state  as  far  as  external  appearance,  and  it  was  still  free  from  tenderness ; 
there  had  been  no  relief  from  the  bowels,  and  no  flatus  passed  ;  the  urine  con- 
tinued abundant ;  she  had  had  a  restless  night,  and  suffered  occasionally  from 
hiccough. 

14th. — There  was  no  improvement.  There  was  neither  pain  nor  tender- 
ness in  the  abdomen,  nor  was  it  more  distended  ;  she  was  not  disturbed  by 
vomiting,  but  was  partially  under  the  influence  of  opium,  which  had  been 
continued  without  calomel ;  nutrient  enemata  were  used. 

17th She  died,  rather  less  than  twelve  days  from  the  time  of  strangula- 
tion. 

Inspection  took  place  about  twelve  hours  after  death.  On  opening  the 
abdomen,  the  small  intestines  were  found  moderately  distended,  but  on  the 


440  INTERNAL    STRANGULATION. 

fingers  being  passed  towards  the  pelvis  the  strangulated  bowel  gave  way,  and 
some  fecal  extravasation  took  place;  the  peritoneum  was  inflamed;  it  was 
dry,  and  deep  red  lines  existed  at  the  points  of  contact  of  the  intestine;  the 
stomach  and  transverse  colon  were  moderately  distended;  the  small  intestine 
was  still  more  enlarged.  In  the  pelvis  several  coils  of  small  intestine  were 
found  almost  black  in  color;  there  was  iV-cal  extravasation,  hut  this  probably 
only  took  place  after  death;  at  the  site  of  the  right  internal  abdominal  ring, 
was  a  roughened  and  injected  state  of  the  peritoneum,  as  if  adhesion  had 
existed ;  and  there  was  a  similar  condition  also  on  the  right  side.  On  turning 
aside  the  small  intestine,  a  firm  band  of  adhesion,  round  and  dense,  was  found 
to  extend  from  the  region  of  the  caecum  to  the  margin  of  the  pelvis,  at  the 
termination  of  the  sigmoid  flexure ;  through  this  loop  several  coils  of  ileum 
had  passed,  and  had  become  strangulated.  The  band  of  adhesion  passed  from 
the  mesentery  of  the  ileum  to  the  mesentery  of  the  sigmoid  flexure,  and  it 
appeared  to  be  the  free  perforated  margin  of  the  latter  mesentery;  the  band 
was  thin,  and  contained  vessels;  and  it  was  doubtful  whether  it  was  really 
a  band  of  inflammatory  adhesion,  or  a  part  of  the  sigmoid  mesentery,  which 
had  become  thinned  and  perforated,  and  so  presented  an  abnormal  and  free 
edge.  The  strangulation  was  four  feet  from  the  caecum,  and  nearly  two  feet 
in  length.  The  mesentery  of  the  strangulated  part  was  infiltrated  with  blood  ; 
its  peritoneum  was  almost  black,  and  in  several  parts  it  was  sloughing.  The 
mucous  membrane  at  the  upper  end  of  the  strangulation  presented  an  exten- 
sive slough,  and  the  coats  were  destroyed;  at  the  lower  end  the  sloughing 
was  rather  less  extensive  and  advanced.  The  coils  of  intestine  contained 
within  the  adhesion  were  united  by  moderately  firm  lymph. 

The  appendix  caeci  was  perfectly  free ;  below  the  band  the  small  intestine 
was  contracted,  so  also  was  the  sigmoid  flexure,  but  the  transverse  colon  was 
moderately  distended  with  flatus.  The  stomach  was  not  at  all  dissolved ;  but 
the  whole  of  the  mucous  membrane  was  intensely  congested  with  very  minute 
arborescent  vessels. 

The  liver,  kidneys,  and  spleen  were  healthy.  In  the  lower  lobe  of  the 
left  lung  there  were  several  lobules,  in  a  state  of  red  and  gray  hepatization ; 
and  the  whole  of  that  lobe  was  in  a  state  of  early  pneumonic  consolidation ; 
the  other  lung  was  healthy.  The  heart  was  normal ;  its  right  cavities  were 
filled  with  blood. 

In  this  case,  it  is  probable  that  a  portion  of  intestine  had  been 
encircled  by  the  band  for  some  time,  for  adhesions  had  evidently 
existed  between  that  part  of  the  ileum  and  the  parietes  near  the 
inguinal  canal,  and  occasional  pain  had  been  experienced  in  the 
abdomen;  the  distension  of  the  incarcerated  part  and  the  intrusion 
of  other  coils  led  to  strangulation. 

It  was  diagnosed  before  death,  that  the  obstruction  was  in  the 
small  intestine,  from  the  moderate  distension,  the  short  time  that 
elapsed  before  vomiting  came  on,  and  the  character  of  the  ejected 
matters.  The  quantity  of  urine  did  not  assist  us  here ;  the  vomiting 
was  moderate,  because  purgatives  and  irritants  were  avoided ;  the 
distension  also  was  rather  in  the  central  part  of  the  abdomen,  and 
the  transverse  and  descending  colon  could  not  be  traced,  as  in  ob- 
structed sigmoid  flexure.  As  to  the  treatment,  I  believe  it  was 
most  judicious  after  admission  into  Guy's  Hospital,  and  that  life  was 
by  that  means  prolonged  for  several  days,  and  the  patient  spared 
intense  suffering.  The  opium  quieted  the  peristaltic  action  and 


INTERNAL    STRANGULATION.  441 

violent  vomiting,  and  if  the  latter  had  continued  perforation  would 
probably  have  taken  place  at  an  early  period. 

In  reference  to  opening  the  abdomen,  if  it  had  been  attempted  at 
a  very  early  period,  the  band  might  perhaps  have  been  divided,  but 
during  the  latter  days  of  life  the  intestine  was  in  a  semi-gangrenous 
state,  and  the  operation  would  probably  have  been  hastily  termi- 
nated by  the  rupture  of  the  strangulated  bowel. 

CASE  CXLIV.  Internal  Strangulation.  A  Loop  of  Small  Intestine 
passed  into  a  hole  in  the  Great  Omentum — J.  D — ,  aet.  45,  was  apparently 
in  the  enjoyment  of  good  health  till  Monday  morning,  November  29th.  On 
that  day  lie  alighted  suddenly  from  a  chaise ;  at  the  same  moment  he  felt  sudden 
pain  in  the  abdomen,  low  down  in  the  right  iliac  region;  about  noon  he  began 
to  vomit,  and  the  vomiting  recurred  frequently.  He  had  never  suffered  from 
any  irregular  action  of  the  bowels,  and  had  previously  had  good  health.  He 
was  bled,  and  calomel  with  purgatives  administered,  without  any  effect.  Ene- 
mata  were  returned  with  fecal  odor.  On  the  third  day  the  abdomen  was 
moderately  distended,  but  free  from  tenderness;  the  pulse  was  84;  and  the 
tongue  was  injected  and  fissured.  There  had  been  no  action  from  the  bowels, 
and  the  vomiting  continued. 

On  the  fourth  day,  there  was  no  change  in  the  symptoms ;  he  was  placed 
in  a  warm  bath,  and  water  injected  into  the  rectum.  Whilst  in  the  bath  he 
became  much  worse,  collapse  came  on,  and  death  followed  in  five  hours. 

Inspection — The  peritoneum  contained  thin  fecal  fluid.  The  coils  of  the 
large  intestine  were  lying  in  front  of  the  omentum,  which  descended  into  the 
pelvis.  The  small  intestine  was  adherent  to  the  anterior  abdominal  parietes, 
and  air  was  found  to  escape  from  a  perforation  in  the  small  intestine.  A 
loop  of  ileum,  six  inches  from  the  caacum,  together  with  the  mesentery,  had 
passed  through  an  opening  in  the  great  omentum,  and  had  led  to  the  fatal 
strangulation  and  subsequent  perforation.  There  was  no  ulceration  in  the 
whole  of  the  canal. 

In  this  case  we  had  sudden  occurrence  of  symptoms ;  the  position 
of  the  pain  indicated  the  seat  of  the  disease,  and  the  vomiting  came 
on  a  few  hours  after  pain,  indicating  an  affection  of  the  small  rather 
than  of  the  large  intestine.  The  case  showed  that,  although  the  ab- 
domen was  free  from  pain  and  tenderness,  the  movement  required  to 
place  the  patient  in  a  warm  bath,  and  the  injection  of  warm  water 
into  the  rectum,  were  not  free  from  danger;  they  hastened  fatal  per- 
foration and  peritonitis ;  how  much  more  easily  would  such  an  effect 
have  followed  from  more  sudden  and  violent  exertion. 

CASE  CXLV.  Internal  Strangulation  of  the  last  eighteen  inches  of  the 
Small  Intestine  by  means  of  a  Diverticulum  from  the  Ileum,  fatal  after 
thirty-eight  hours — Henry  W — ,  aet.  19,  had  been  employed  as  a  lead  and 
color  manufacturer  in  Tooley  Street ;  he  had  had  colic  a  year  previously,  but 
at  the  time  of  admission  into  Guy's  Hospital  no  trace  of  lead  existed  on  the 
gums.  He  was  of  pale  complexion,  with  light  hair,  and  he  enjoyed  his  usual 
health  till  Sunday,  July  28th,  at  7  P.  M.,  when  soon  after  drinking  some 
beer  he  was  seized  with  pain  at  the  lower  part  of  the  abdomen,  towards  the 
right  side.  About  an  hour  after  this  he  had  moderate  action  of  the  bowels. 
Sickness  came  on  about  9  o'clock,  and  during  the  night  he  vomited  whatever 
he  took.  An  injection,  administered  before  admission,  came  away  with 
scarcely  a  tinge  of  feculent  matter.  He  was  brought  to  Guy's  at  10  P.  M., 


442  INTERNAL    STRANGULATION. 

July  20th,  and  placed  under  Dr.  Barlow's  care,  in  an  almost  pulseless  state ; 
pulse  144,  the  face  and  extremities  were  cold,  there  was  frequent  eructation, 
the  abdomen  was  rigid,  tyrnpanitic,  and  very  tender  on  pressure  ;  the  tongue 
was  flabby ;  no  urine  had  passed ;  and  his  respiration  was  entirely  thoracic. 

At  9  A.  M.,  on  the  day  after  admission,  the  abdomen  was  tense,  slightly 
hollowed  out  in  the  right  hypochondriac  region,  arid  tender  on  pressure.  He 
was  very  restless,  turning  from  side  to  side  in  bed,  and  his  legs  were  occa- 
sionally drawn  up.  He  had  passed  a  disturbed  night,  with  the  same  symp- 
toms as  on  admission  ;  his  pulse  could  scarcely  be  felt.  Shortly  after-tins  he 
was  allowed  by  the  nurse  to  rise  up  in  bed,  became  faint,  and  died  in  about 
half  an  hour,  thirty-eight  hours  after  the  commencement  of  the  pain. 

On  examining  the  abdomen,  several  pints  of  bloody  serum  were  found  in 
the  peritoneal  sac.  The  whole  of  the  small  intestine  was  much  distended  ; 
but  several  coils,  corresponding  to  the  last  eighteen  to  twenty-four  inches  of 
the  ileum,  were  in  a  state  of  approaching  gangrene.  The  latter  portion  had 
become  strangulated  by  a  diverticulum  from  the  small  intestine,  about  one 
and  a  half  inches  in  length,  and  by  a  band  passing  from  the  mesentery  to 
the  ca?cal  end  of  this  pouch.  The  large  intestine  was  less  contracted  than  is 
generally  observed  in  such  cases.  There  was  evidence  of  general  peritonitis, 
lymph  being  effused  between  the  coils  of  the  intestine.  The  mucous  mem- 
brane was  continued  into  the  pouch,  and  much  imperfectly  masticated  cocoa- 
nut,  and  the  remains  of  gooseberries,  which  had  been  eaten  on  the  morning 
of  the  attack,  were  found  in  the  intestine.  The  remaining  viscera  were 
healthy. 

This  case  is  worthy  of  being  recorded  as  presenting  peculiar  diffi- 
culties in  diagnosis;  for  whilst  the  urgent  vomiting,  the  state  of  the 
abdomen,  and  the  mode  of  the  attack,  pointed  it  out  as  one  of  me- 
chanical obstruction,  the  great  depression  and  rapid  termination 
seemed  to  refer  it  to  rupture  of  the  bowel.  These  latter  peculiar! 
ties,  however,  probably  arose  from  the  extent  and  completeness  of 
the  strangulation  leading  to  speedy  gangrene.  Although  the  pain 
was  situated  towards  the  right  side,  the  symptoms  were  not  those 
usually  presented  by  caecal  mischief.  The  first  indication  of  disease 
was  pain  resembling  colic  after  taking  some  malt  liquor,  and  it  is 
probable  that  the  indigestible  substances  which  he  had  eaten  tended 
to  excite  distension  and  irritation  of  the  mucous  membrane.  A  slight 
constriction  of  the  canal  may  become  so  increased  by  irregular  peri- 
action  and  over-distension  as  to  become  complete ;  thus  a  patient 
may  for  years  suffer  from  slight  attacks  of  pain  and  from  irregularity 
of  the  bowels,  till  after  some  indiscretion  in  diet  he  has  a  recurrence 
of  pain  and  vomiting  with  constipation ;  no  tenderness  of  the  abdo- 
men may  be  present,  but  rigidity  of  the  abdominal  muscles;  the 
vomiting  may  continue,  no  further  action  from  the  bowels  take  place 
but  hiccough,  rapid  prostration  of  strength,  and  death  speedily  follow. 
The  diagnosis  in  such  a  case  is  beset  with  difficulty.  Abercrombie 
records  several  instances  of  this  kind,  where  there  was  adhesion 
without  apparent  narrowing  of  the  canal,  existing  probably  for  yc.-irs, 
till,  from  some  unknown  cause,  complete  and  fatal  obstruction  took 
•place;  and  cases  repeatedly  present  themselves  in  which  organic  dis- 
ease of  great  extent  has  existed  for  a  considerable  period,  and  symp- 
toms of  obstruction  are  manifested  only  a  short  time  before  death. 


INTERNAL    STRANGULATION.  443 

CASE  CXLVI.  Internal  Strangulation  of  a  large  part  of  the  Small 
Intestine.  Death  on  the  fifth  day. — Edward  J.  T.,  set.  27,  was  admitted 
under  the  care  of  Dr.  Rees  into  Guy's  Hospital,  October  llth,  1861,  and 
died  on  the  14th.  He  was  a  spare  man,  with  a  rather  sallow  and  anxious 
expression,  and  his  eyes  were  sunken.  The  skin  was  cool ;  he  stated  that  he 
was  quite  well  till  Wednesday,  the  9th,  when,  having  returned  to  his  work 
after  dinner,  sudden  pain  came  on  in  the  abdomen,  close  to  the  umbilicus ;  he 
sent  for  a  dose  of  castor-oil,  which  at  once  produced  vomiting ;  the  vomiting 
continued  till  his  admission  on  Friday.  The  rejected  matters  had  the  ap- 
pearance of  fluid  feces,  but  the  fecal  smell  was  not  very  manifest.  The 
tongue  was  clean,  the  pulse  compressible ;  there  was  no  evidence  of  external 
hernia;  the  abdomen  was  rather  small,  and  there  was  no  distension  of  the 
colon  :  neither  was  there  any  tenderness,  nor  tumor,  nor  hiccough.  Calomel 
and  opium  were  given,  and,  after  an  injection,  flatus  was  discharged  ;  after  a 
second  injection  flatus  and  some  fecal  matter  were  passed  :  the  pain  ceased  ; 
during  the  twenty-four  hours  a  pint  of  urine  was  passed.  On  the  14th  col- 
lapse came  on,  and  in  a  few  hours  death  took  place. 

On  inspection,  the  lungs  were  found  in  a  healthy  state ;  the  heart  was 
small,  the  right  side  was  flaccid,  the  left  was  firmly  contracted.  On  opening 
the  abdomen  a  band  of  adhesion  was  at  once  seen  constricting  a  large  portion 
of  the  small  intestine.  The  general  peritoneum  was  clear,  smooth,  and 
shining;  the  constriction  was  formed  by  a  hole  near  to  the  centre  of  the 
omentum,  the  edges  of  which  were  thickened;  and  the  ends  of  the  constrict- 
ing fold  were  adherent  to  the  brim  of  the  pelvis.  The  stomach  and  about  six 
feet  of  the  jejunum  were  distended;  the  rest  of  the  jejunum  and  the  ileum. 
nearly  to  the  caecum  had  passed  through  the  opening.  The  constricted  part 
was  contracted ;  its  peritoneum  was  partially  inflamed,  and  in  one  part  soft- 
ened, but  there  was  no  perforation.  The  colon  was  small  and  empty.  The 
kidneys  and  the  liver  were  healthy. 

The  symptoms  of  strangulation  in  this  case  were  suddenly  de- 
veloped; and  it  was  evident  that  the  small  intestine  was  the  affected 
part,  from  the  early  period  at  which  vomiting  came  on,  the  absence 
of  distension  of  the  abdomen,  and  the  small  quantity  of  urine  which 
was  passed.  I  have  usually  regarded  the  passage  of  flatus  as  a  hope- 
ful symptom,  but  in  this  case  it  had  not  its  usual  favorable  import; 
however,  the  strangulation  was  at  that  time  either  not  complete,  or 
the  flatus  merely  came  from  below  the  incarcerated  intestine.  The 
early  period  at  which  death  took  place  was  probably  due,  in  part,  to 
the  great  extent  of  the  strangulated  bowel,  which  amounted  to  the 
whole  of  the  ileum  and  part  of  the  jejunum;  but  the  cause  of  the 
sudden  collapse,  a  few  hours  before  the  fatal  termination,  could  not 
be  ascertained,  for  no  perforation  existed,  and  the  strangulated  por- 
tion only  had  its  peritoneal  investment  inflamed.  The  omentum  had 
first  become  adherent,  then  atrophied  and  perforated,  and  on  sudden 
movement  or  distension  the  bowel  passed  through  the  opening. 

CASK  CXLVII.  Internal  Strangulation.  Old  Peritoneal  Adhesions. 
Peritonitis.  Suppuration — John  D — ,  aet.  33,  a  laborer,  was  admitted 
under  Dr.  Wilks's  care  into  Guy's  Hospital  June  8th,  1860.  Till  the  previous 
Sunday,  June  3d,  he  had  felt  in  good  health ;  and  on  the  following  day,  at 
1  A.  M.,  he  was  seized  with  pain  in  the  abdomen,  and  vomiting  shortly  came 
on.  Aperient  medicines  were  given,  and  the  vomiting  increased  in  severity; 
the  ejecta  became  stercoraceous ;  but  no  action  of  the  bowels  took  place.  He 


444  INTERNAL    STRANGULATION. 

had  a  sallow  and  anxious  expression  of  countenance  when  he  was  brought  to 
Guy's;  the  abdomen  was  moderately  distended,  and  rather  tense;  there  was 
slight  pain;  an  injection  on  the  previous  day  had  brought  away  some  fecal 
matter,  but  he  was  not  sure  that  any  flatus  had  passed;  the  urine  was  scanty; 
the  tongue  was  slightly  injected  and  furred;  the  pulse  was  compressible.  A 
grain  of  opium  was  ordered  every  four  hours;  and  a  warm  poultice  was  applied. 
On  the  9th  the  countenance  was  less  anxious;  but  the  eyes  were  sunken ;  the 
pulse  quiet,  the  skin  normal,  the  abdomen  was  not  distended,  and  the  muscles 
were  hard  and  rigid,  especially  around  the  umbilicus,  where  he  complained 
of  pain;  there  had  been  no  action  from  the  bowels,  nor  had  any  flatus  been 
passed;  the  urine  was  moderate  in  quantity;  the  vomiting  of  offensive  matter 
continued.  On  the  llth,  as  there  was  no  improvement,  Dr.  Wilks  directed 
that  he  should  be  placed  in  a  warm  bath,  and  cold  water  poured  upon  the 
abdomen.  On  the  12th  the  patient  was  in  greater  distress,  and  in  more 
severe  pain ;  he  had  had  no  sleep,  for  as  soon  as  he  dozed  he  was  at  once 
awoke  by  sudden  pain  darting  through  him:  the  pulse  was  100,  hard;  the 
tongue  was  rather  dry,  the  vomiting  more  severe,  and  stercoraceous ;  the 
abdomen  was  ruot  distended,  and  still  rigid;  the  pain  was  especially  situated 
in  the  umbilical  region  and  about  the  caecum.  Opium  gr.  j  was  continued 
every  four  hours;  and  a  long  tube  was  passed  and  water  injected  into  the 
bowel.  On  the  13th  he  was  in  still  greater  pain.  Six  pints  of  water  had 
been  thrown  up  three  times;  and  the  dulness  consequent  on  the  injection 
extended  apparently  as  far  as  the  caecum  ;  some  scybala  were  brought  away, 
and  the  vomiting  became  less. 

On  the  16th  he  had  not  vomited  for  three  days;  on  the  previous  day  a  six- 
pint  injection  was  again  thrown  up,  and  some  scybala  passed;  flatus  was 
discharged;  the  pulse  was  quiet,  the  skin  cool;  the  urine  was  abundant;  he 
had  suffered  during  the  morning  from  severe  twisting  pain  in  the  region  of 
the  umbilicus,  and  the  pain  continued;  but  his  general  expression  was  much 
improved — more  cheerful  and  less  haggard ;  he  was  able  also  to  take  beef 
tea.  To  continue  the  opium. 

During  the  afternoon  of  June  16th,  on  the  thirteenth  day  of  obstruction, 
the  bowels  acted.  On  the  17th  the  bowels  acted  twice.  On  the  18th  he 
was  cheerful,  but  suffered  occasional  pain  in  the  abdomen.  In  a  few  days 
he  was  considered  sufficiently  well  to  leave  the  hospital. 

On  October  17th,  1869,  he  was  admitted  into  St.  George's  Hospital,  under 
Dr.  Fuller's  care,  and  1  am  indebted  to  the  kindness  of  Dr.  Dickinson  for 
the  following  report: — The  abdominal  pain  had  never  entirely  left  him  since 
he  had  been  in  Guy's  Hospital.  "When  admitted  (October  17th)  he  was 
much  emaciated  and  sallow.  The  abdomen  was  somewhat  tympanitic,  and 
slightly  painful,  but  not  tender.  The  bowels  were  regular;  the  motions  pale. 
He  was  weak  and  occasionally  had  cramp  in  the  abdomen;  his  strength 
failed,  the  tongue  became  red  and  glazed,  and  the  pulse  rapid.  On  the  8th 
he  was  more  prostrate,  and  the  pulse  quick  and  irregular.  Vomiting  came 
on  and  continued  all  day.  leaving  him  at  last  faint  and  sinking,  in  which 
condition  he  died,  in  full  possession  of  his  faculties." 

'•'•The  inspection  was  made  sixteen  hours  after  death.  The  body  was  much 
emaciated ;  the  abdomen  very  tympanitic.  The  brain  was  healthy.  There 
were  extensive  old  pleural  adhesions  on  both  sides.  The  lungs  and  heart 
were  healthy.  All  the  opposite  surfaces  of  the  peritoneum  were  closely  united 
by  old  adhesions.  In  front  the  parietal  peritoneum  was  thus  united  to  the 
great  omentum,  which  was  of  great  density  and  much  thickened  by  old  in- 
flammation. It  was  closely  adherent  below  to  the  walls  of  the  abdomen  near 
the  pelvis,  so  that  on  dissecting  off  the  abdominal  walls,  nothing  else  was 


INTERNAL    STRANGULATION.  445 

seen.  On  cutting  through  the  omentum,  a  large  collection  of  thin  fetid  pus 
was  found  bathing  the  intestine;  there  could  not  have  been  less  than  a  quart 
of  this  fluid.  The  small  intestines  were  much  convoluted,  and  in  some  places 
greatly  distended ;  they  were  vascular,  and  their  surfaces  smeared  in  many 
places  with  recent  lymph.  Besides  these,  there  were  old  adhesions  between 
neighboring  coils.  The  small  intestines  were  carefully  traced  down  from  the 
stomach  (which  was  itself  collapsed,  but  healthy),  but  no  trace  of  obstruction 
could  be  found  either  in  it  or  in  the  large  intestine.  The  coats  of  the  bowel 
were  in  many  places  much  thickened,  so  as  to  resemble  tripe.  No  morbid 
condition  of  the  mucous  membrane  was  anywhere  found.  The  mesenteric 
glands  were  healthy,  and  near  the  ileo-caecal  valve  was  a  large  chalky  mass, 
which  apppeared  to  have  originated  in  a  diseased  gland.  The  liver  and 
kidneys  were  healthy." 

When  this  patient  was  under  the  care  of  Dr.  Wilks  he  was  suffer- 
ing from  the  symptoms  of  internal  strangulation  of  the  small  intestine, 
as  shown  by  colic,  with  constipation  and  stercoraceous  vomiting,  &c. ; 
and  from  the  subsequent  inspection,  which  revealed  the  presence  of 
old  peritoneal  adhesions,  it  would  seem  probable  that  the  obstruction 
arose  from  this  cause,  namely,  the  pressure  of  adhesions,  perhaps 
rendered  complete  by  enteric  inflammation.  The  thickening  of 
several  portions  of  intestine  indicated  the  presence  of  chronic  im- 
pediment in  the  transit  of  the  fecal  contents.  The  cause  of  death 
appeared  to  be  exhaustion  from  recurrent  peritoneal  attacks,  termi- 
nating in  suppuration.  The  advantage  of  an  opiate  plan  of  treat- 
ment, with  enemata,  was  shown  in  the  subsidence  of  the  severe 
symptoms  of  the  first  attack. 

CASE  CXLYIII.  Lead  Colic.  Internal  Strangulation  of  the  Intestine 
from  old  disease  of  a  Mesenteric  Gland,  and  subsequent  Fibroid  Contraction. 
( Reported  by  Mr.  George  Eastes.) — Charles  S — ,  set.  29,  was  admitted  into 
Guy's  Hospital,  under  Dr.  Rees's  care,  November  8th,  and  died  on  the  20th. 
He  had  been  a  painter  by  trade,  but  had  left  that  occupation  to  become  a 
chimney-sweep,  seven  or  eight  months  before  his  last  illness,  on  account  of 
the  attacks  of  colic  from  which  he  suffered;  but  even  when  a  child  he  fre- 
quently suffered  from  pain  in  the  abdomen.  The  first  attack  of  this  sort 
occurred  three  years  previously,  but  that  had  been  preceded  by  many  threat- 
enings;  the  next  was  twelve  months  later;  in  six  months  more,  the  colic 
came  on  a  third  time ;  and  from  that  time  he  had  repeated  attacks,  the  inter- 
val of  freedom  from  pain  lessening  in  duration;  so  that  during  five  months 
prior  to  admission,  he  was  quite  laid  aside,  on  account  of  the  abdominal  pain 
and  distress  being  almost  constant.  During  the  latter  part  of  his  illness  he 
had  been  much  annoyed  by  vomiting;  this  symptom  had  harassed  him  con- 
tinually, and  it  had  generally  come  on  about  two  hours  after  food,  of  what- 
ever kind  it  might  be ;  the  bowels  were  meantime  costive,  so  as  only  to  be 
opened  by  injection ;  the  pain  gave  him  no  rest,  by  night  nor  by  day,  and 
it  was  accompanied  by  gurgling  and  spasm  of  the  abdominal  walls;  the  peri- 
staltic movement  of  the  intestine  became  visible.  The  patient  described  the 
passage  and  quantity  of  urine  as  free.  He  did  not  suffer  from  headache,  nor 
from  pain  in  the  joints;  but  he  had  a  well-marked  lead  line  on  his  gums. 
His  complexion  was  dark,  and  he  had  a  large  quantity  of  black  hair;  his 
countenance  was  anxious ;  the  conjunctivas  were  dingy;  the  tongue  was  red 
at  the  tip  and  edges ;  the  pulse  68.  The  abdomen  was  not  tender  during 
the  intervals  of  quiet ;  but  as  soon  as  the  pain  came  on,  the  rectus  muscle 


446  INTERNAL    STRANGULATION. 

\\n<  drawn  up  into  distinct  knots,  and  then  the  abdomen  became  so  tender 
tluil  lie  could  not  bear  even  the  bedclothes  to  rest  upon  him.  He  was  not 
always  sick,  but  generally  vomited  for  a  day  or  two  at  intervals  of  two  or 
three  months.  The  appetite  was  pretty  good,  but  for  four  months  he  had 
taken  only  bread  and  arrowroot;  meat  was  almost  certain  to  produce  vomiting 
soon  after  taking  it.  His  bowels  were  much  constipated,  acting  only  every 
three  or  four  days;  and  the  evacuations  were  hard  and  scybalous.  There 
was  slight  difficulty  in  micturition,  and  the  urine  contained  lithatcs. 

The  bowels  acted  slightly  on  two  occasions  during  the  next  twelve  days, 
but  the  pain  and  vomiting  continued  more  severely,  and  he  died  November 
20th,  after  a  night  of  agonizing  pain. 

The  inspection  was  made  thirty-six  hours  after  death.  The  thoracic  vis- 
cera were  healthy.  Abdomen:  there  was  general  and  acute  peritonitis;  nearly 
the  whole  of  the  ileum  and  jejunum  were  almost  of  a  black  color,  and  greatly 
distended,  and  in  several  parts  the  peritoneal  surface  had  ulcerated,  exposing 
the  muscular  coat,  apparently  from  distension.  The  small  intestine  was 
drawn  backward  towards  the  spine  from  contraction  of  the  mesentery;  and 
on  examining  the  ileum,  near  to  the  CEecum,  a  hard  mesenteric  gland  pro- 
jected into  the  intestine,  and  had  led  to  fibroid  thickening  and  contraction ; 
at  this  part  the  muscular  coat  of  the  ileum  was  much  hypertrophied,  and 
projected,  like  a  nodule,  into  the  intestine;  it  closely  resembled  thickening 
of  the  pylorus  from  fibroid  degeneration ;  the  hypertrophy  of  'the  muscular 
coat  extended  some  distance  up  the  ileum,  and  contrasted  remarkably  with 
the  thin  muscular  coat  below  the  stricture;  the  mucous  coat  was  also  thick- 
ened, and  slightly  ulcerated  $  the  peritoneal  coat  presented  the  ulceration 
before  mentioned;  the  colon  was  contracted.  The  other  viscera  were  healthy. 

The  constriction  in  this  instance  apparently  originated  in  disease 
of  one  of  the  rnesenteric  glands  during  early  life,  fibroid  thickening 
took  place  at  that  part  of  the  mesentery,  which  led  to  partial  and 
afterwards  to  fatal  occlusion  and  peritonitis.  The  intense  colic  from 
which  the  patient  suffered,  was  produced  by  the  irregular  peristaltic 
and  spasmodic  efforts  to  overcome  this  obstruction ;  attacks  of  colic 
appear  to  have  come  on  in  early  life,  before  he  had  adopted  the  trade 
of  a  painter ;  afterwards,  it  is  probable  that  the  lead  aggravated  them. 
.  The  circumstance  of  chronic  poisoning  by  lead  and  the  blue  line 
along  the  gums  tended  to  obscure  correct  diagnosis;  the  intensity  of 
the  colic,  however,  the  intolerance  of  pressure,  and  the  supervention 
of  peritonitis,  were  all  opposed  to  simple  poisoning  by  the  absorption 
of  lead. 

CASE  CXLIX.  Mechanical  Obstruction  terminating  favorably  after 
seventy-eight  hours — For  many  of  the  particulars  of  the  following  case  I  am 
indebted  to  my  friend  Sir  William  Gull. 

J.  S — ,  set.  33,  a  coal  porter  on  a  wharf,  rose  on  the  morning  of  the  26th 
June,  1850,  in  his  usual  health,  and  before  going  to  his  work,  went,  as  his 
habit  was,  to  stool,  and  had  a  good  evacuation  from  the  bowels.  About  half 
an  hour  afterwards,  whilst  stooping  to  fill  a  sack,  he  was  suddenly  seized  with 
a  sharp  pain  across  the  abdomen  in  the  hypogastric  region,  accompanied  by 
a  sense  of  constriction.  He  was  obliged  to  leave  his  work  and  to  go  home ; 
in  a  short  time  he  began  to  vomit,  and  after  the  attack  was  unable  to  pass 
anything  downwards.  He  was  treated  by  Mr.  Mitchell,  of  Deptford,  but 
without  effect,  and  on  the  evening  of  the  following  day,  forty  hours  from  the 
accession  of  the  symptoms,  he  was  sent  to  the  hospital  with  a  note,  saying 


INTERNAL    STRANGULATION.  447 

that  no  hernia  could  be  found,  but  that  an  internal  obstruction  was  suspected. 
The  assistance  of  Mr.  Cock  was  obtained,  who  examined  all  the  outlets,  but 
could  detect  no  protrusion.  On  admission  he  had  the  usual  symptoms  of 
strangulated  hernia,  urgent  vomiting,  anxious  countenance,  pulse  rather  fre- 
quent; the  temperature  of  the  surface  was  depressed,  the  abdomen  rigid,  and 
rather  tumid,  and  slightly  tender  on  pressure,  urine  small  in  quantity,  and 
high  colored.  He  was  ordered  a  grain  of  opium  every  four  hours,  and  to 
abstain  from  relieving  his  thirst.  The  report  of  the  third  day  at  noon  was, 
that  he  had  passed  a  restless  night,  vomiting  continually.  He  was  seen  early 
in  the  morning,  everything  was  interdicted,  even  to  cold  water,  and  he  was 
then  better,  the  paroxysms  of  pain  in  the  abdomen  being  less  urgent.  As  he 
was  under  the  influence  of  opium  the  dose  was  diminished  to  half  a  grain, 
and  a  copious  enema  of  salt  and  water  was  thrown  by  a  long  flexible  tube  into 
the  rectum  ;  it  passed  up  readily,  but  without  bringing  away  any  feculent 
matter.  In  the  evening  he  was  restless,  his  countenance  was  anxious,  the 
vomiting  and  other  symptoms  continuing  as  before. 

Fourth  day,  eight  o'clock  A.  M — He  vomited  during  the  night  in  con- 
siderable quantity;  the  abdomen  was  tense,  and  coils  of  distended  intestine 
could  be  partially  traced,  the  peristaltic  action  rendering  them  prominent, 
with  increase  of  pain  in  the  abdomen,  of  which  he  complained  bitterly.  His 
countenance  was  still  expressive  of  great  anxiety,  and  the  features  were 
shrunk.  He  had  passed  about  half  a  pint  of  urine,  clear  and  well  colored; 
the  pulse  was  accelerated,  and  diminished  in  power.  He  was  ordered  to  go 
on  with  the  opium.  During  the  morning  his  abdomen  was  exposed  for  some 
time,  whilst  a  sketch  was  made  of  its  peculiar  form,  and  the  position  and 
direction  of  the  prominent  convolutions,  in  order  to  determine  more  accu- 
rately the  precise  seat  of  obstruction  ;  when  suddenly,  about  noon,  he  expressed 
himself  relieved,  saying,  that  "something  had  given  way  within  him,"  and 
this  feeling  was  quickly  followed  by  a  copious  flow  of  liquid  feces  inundating 
the  bed.  From  this  time  he  steadily  recovered,  the  vomiting  and  hiccough 
at  once  subsided,  and  the  face  acquired  a  cheerful  expression. 

V. 

Certainly  no  cases  present  a  less  promising  prognosis  than  those 
of  mechanical  obstruction  of  the  intestines,  nor  has  the  enterprise  of 
modern  surgery  yet  succeeded  in  diminishing  their  mortality.  The 
case  here  recorded  presented  points  of  no  common  interest;  that  it 
was  one  of  mechanical  obstruction  there  can  be  but  little  doubt,  and 
if  so,  we  had  an  instance  of  its  spontaneous  removal,  and  it  answers 
in  the  affirmative  the  question  whether  we  can  hope  for  a  successful 
result  in  mechanical  obstruction  without  surgical  interference.  From 
what  we  have  seen  in  hospital  practice,  there  is  reason  to  believe 
that  irregular  peristaltic  action  following  upon  indigestible  food,  is 
not  an  uncommon  cause  of  internal  displacement ;  but  in  the  case 
here  recorded,  it  came  on  after  a  night's  fast,  and  before  any  rneal 
had  been  taken  in  the  morning.  The  patient  rose  as  well  as  usual ; 
the  bowels  acted  according  to  his  daily  habit;  he  went  to  his  work 
in  good  health,  but  whilst  in  a  stooping  position  the  pain  came  on. 
It  need  not  be  mentioned,  that  there  was  neither  history  nor  trace  of 
lead  in  the  system,  nor  indeed  were  the  symptoms  such  as  arise  from 
poisoning  by  that  mineral.  The  only  remedy  trusted  to  in  the  treat- 
ment was  opium,  but  the  happy  termination  of  the  case  whilst  the 
abdomen  was  exposed  to  the  cold  air,  renders  it  probable  that 
moderation  of  temperature  had  somewhat  to  do  with  the  result.  The 


448  INTERNAL    STRANGULATION. 

application  of  cold  has  been  suggested  in  such  cases,  and  has  much 
in  theory  to  recommend  it,  and  it  might  be  expected,  in  conjunction 
with  opium,  to  effect  all  that  mere  treatment  can  effect.  For,  sup- 
pose a  portion  of  intestine  to  have  insinuated  itself  under  any  acci- 
dental band  in  the  abdomen,  by  what  means  can  we  so  well  hope  to 
liberate  it,  as  by  reducing  its  volume,  and  by  allaying  the  vomiting? 
I  would  also  suggest  whether  opium  suppositories  would  not  some- 
times more  efficiently  promote  the  latter  object  than  opium  in  the 
stomach.  Of  the  opiate  plan  of  treating  intestinal  obstruction  too 
much  cannot  be  said.  It  has  both  reason  and  experience  on  its  side; 
and  yet  in  the  reports  daily  given  of  such  cases,  purgatives  form 
generally  the  early  part  of  the  treatment ;  and  they  are  persevered 
in  until  the  stomach  will  bear  them  no  longer,  serving  only  to  ex- 
haust the  patient  and  to  increase  the  symptoms.  This  case  also 
shows  the  importance  of  abstaining  from  food,  which  not  only  dis- 
tends the  bowel,  but  increases  the  peristaltic  movement  and  augments 
the  pain. 

CASE  CL.  Internal  Strangulation  and  Constipation.  Subsidence  of 
Symptoms.  Death  from  Phthisis — (From  the  Museum  Records.) — William 
H — ,  a  man  of  middle  age,  was  admitted  into  Guy's  in  1829.  There  was 
obstinate  constipation,  vomiting  of  a  stercoraceous  character ;  but  no  hernia 
could  be  detected.  The  symptoms  gradually  subsided,  but  the  patient  died 
from  phthisis  several  months  afterwards. 

On  inspection,  there  were  vomicae  in  the  lungs.  The  intestines  were  ir- 
regularly contracted.  The  appendix  cieci  was  bound  by  adhesion  to  the 
brim  of  the  pelvis,  and  several  bridles  of  adhesions  extended  to  portions  of 
small  intestine  at  this  part ;  one  of  them  was  very  long,  and  had  apparently 
led  to  constriction,  and  to  the  previous  symptoms  of  strangulation.  No 
ulceration  of  the  intestine  existed. 

Tumors  sometimes  become  developed  in  the  mesentery,  and  act  as 
either  the  predisposing,  or  as  the  direct  cause  of  mechanical  obstruc- 
tion. Among  the  records  of  the  inspections  at  Guy's,  is  that  of  a 
boy,  aged  seventeen,  who,  after  a  blow  on  the  abdomen,  two  years 
previously,  had  gradual  distension  of  the  abdomen,  fluctuation,  vom- 
iting, and  constipation.  The  jejunum  was  found  to  be  enormously 
distended.  One  portion  of  the  mesentery  near  the  commencement 
of  the  ileum  contained  numerous  tubercles,  supposed  to  be  cancerous, 
and  the  contraction  around  these  had  led  to  obstruction;  other  tuber- 
cles were  situated  in  the  pelvis. 

CASE  CLI.  Colic,  Simulation  of  internal  Strangulation.  Recovery — 
A  young  man,  set.  22,  badly  nourished,  who  had  resided  in  Rosemary  Lane, 
was  admitted  August  21st,  into  Guy's  Hospital.  He  was  pale  and  despond- 
ing, and  had  been  suffering  severely  during  eight  days.  He  appeared  to 
earn  a  scanty  livelihood  as  a  porter,  and  on  August  14th,  after  taking  his 
breakfast  in  his  usual  health,  he  lifted  about  f  cwt.  upon  a  cart,  when  he  felt 
a  sudden  pain  below  the  left  hypochondriac  region ;  he,  however,  went  to  his 
work,  but  was  taken  back,  "  doubled  up,"  as  he  described  it ;  after  a  few 
hours,  vomiting  came  on,  and  both  pain  and  vomiting  continued  till  admis- 
sion ;  he  had  not  had  any  action  from  the  bowels,  although  repeated  doses  of 
medicine  had  been  taken,  nor  had  there  been  any  hiccough.  He  complained 


INTUSSUSCEPTION.  449 

of  severe  pain  across  the  umbilical  region  ;  the  abdomen  was  neither  hot,  nor 
tender  on  pressure ;  there  was  some  distension  laterally,  and  in  the  position 
of  the  transverse  colon,  otherwise  it  was  contracted.  The  tongue  was  clean 
and  pale  ;  the  pulse  eighty,  and  tolerably  iree  in  volume.  He  had  passed 
but  little  urine,  and  neither  blood  nor  mucus  from  the  bowels.  There  was 
no  hernia,  but  along  the  gums  a  dirty  line  which  somewhat  resembled  lead. 

For  three  months  he  had  been  a  teetotaller,  and  he  had  had  occasional 
pain  in  the  abdomen,  but  no  constipation. 

A  soap  injection  was  administered,  and  calomel  gr.  v,  with  opium  gr.  iss, 
given  as  a  pill.  On  the  22d  and  23d  there  was  no  relief  from  the  bowels, 
no  medicine  was  administered.  On  the  third  day  after  admission  the  bowels 
acted  slightly,  castor-oil  was  then  given,  and  was  followed  by  more  active 
remedies.  The  bowels  acted,  and  he  left  the  hospital  in  a  few  days  com- 
paratively well. 

This  case  was  probably  one  of  colic,  in  which  the  symptoms  came 
on  suddenly  after  exertion;  it  resembled  internal  strangulation,  but 
the  abdomen  never  became  distended;  the  importance  of  not  allow- 
ing too  active  a  plan  of  treatment  was  also  shown,  the  vomiting  be- 
came much  less  after  the  purgative  medicines  had  been  left  off;  the 
calomel  and  opium  with  enemata  were  used  once;  and  on  the  third 
day  the  bowels  were  acted  upon. 

CASES   OF   INTUSSUSCEPTION. 

CASE  CLII.  Colic.  Lumbrici.  Diarrhoea.  Intussusception  of  the 
Kenin  and  Ascending  Colon  into  the  Descending  Colon. — This  case  is  fully 
reported  by  Dr.  Hughes  in  the  '  Guy's  Reports'  of  1856. 

Daniel  D — ,  set.  14,  was  admitted  into  Guy's,  February  27th,  1856,  under 
Dr.  Hughes's  care.  He  had  resided  near  the  Tower,  and  had  assisted  his 
father  as  a  tailor.  His  previous  health  had  been  very  good  till  seven  weeks 
before  admission,  when  he  was  exposed  to  severe  cold,  and  the  following 
morning  he  was  seized  with  acute  pain  in  the  abdomen,  which  continued  for 
several  hours  ;  the  pain  returned  on  the  following  day,  and  similar  paroxysms 
took  place  till  admission,  but  at  uncertain  periods.  The  attacks  generally  came 
on  towards  evening,  and  sometimes  twice  in  the  day.  He  was  free  from  pain 
from  the  21st  to  the  25th,  when  he  took  some  castor  oil,  and  from  that  time  he 
suffered  from  tenesmus,  vomiting  after  meals,  and  loss  of  appetite.  He  de- 
scribed the  pain  as  a  twisting  and  tearing  of  his  intestines  principally  about 
the  umbilicus,  and  he  detected  "  lumps"  in  the  abdomen,  which  disappeared 
on  the  subsidence  of  the  paroxyms,  during  which  he  lay  with  his  legs  curled 
up  and  his  hands  on  the  abdomen  ;  the  duration  of  the  pain  varied,  and  was 
frequently  relieved  by  passing  flatus.  In  the  intervals  he  felt  well.  The 
appetite  was  capricious,  and  sometimes  excessive.  The  bowels  were  open 
twice  a  day,  the  motions  semi-fluid  or  scybalous.  On  admission  he  was 
much  emaciated ;  the  expression  of  countenance  was  one  of  distress ;  there 
was  a  white  fur  on  the  tongue,  and  the  pulse  was  weak  and  compressible. 
Shortly  after  admission  he  voided  an  ascaris  lumbricoides  with  some  mucus. 
Calomel  gr.  v  and  opium  gr.  -|  were  given,  and  were  followed  by  a  senna 
draught.  Poppy  fomentations  were  applied,  and  milk  diet  ordered. 

Repeated  paroxysms  of  severe  pain  came  on  during  the  next  fortnight ; 
but  in  the  intervals  he  was  able  to  go  about  the  ward.  Calomel  and  opium, 
purgatives  and  enemata  were  ordered  ;  diarrhoea  then  supervened  with  tenes- 
mus. On  March  loth  he  was  suffering  from  severe  pain,  the  tongue  was 
29 


450 


INTUSSUSCEPTION. 


coated  with  a  white  fur,  and  the  pulse  was  quick  and  compressible.  The 
abdomen  was  distended  ;  coils  of  intestine  were  visible,  and  there  was  tender- 
ness. He  vomited  a  considerable  quantity  of  green  bilious  fluid,  and  the 
alvine  evacuations  were  of  a  dysenteric  character,  consisting  of  bloody  mucus 
without  fecal  matter.  Notwithstanding  treatment  by  sedatives  and  demul- 
cents, no  relief  was  obtained ;  the  vomiting  became  more  severe ;  another 
lumbricus  was  ejected ;  and  on  the  23d  the  symptoms  of  peritonitis  became 
suddenly  aggravated,  and  he  died  on  the  following  day,  twenty-seven  days 
after  admission,  and  eleven  weeks  after  the  commencement  of  the  attack. 

Inspection — The  body  was  badly  nourished.  The  lungs  and  heart  were 
healthy.  The  abdomen  was  considerably  distended.  On  opening  the  peri- 
toneum the  descending  colon  was  found  to  be  enormously  enlarged  and  full  ; 
so  also  the  sigmoid  flexure,  which  made  a  great  curve  nearly  to  the  right  side 
of  the  abdomen.  The  transverse  colon  could  be  traced  in  a  similar  state  to 
the  right  side  of  the  median  line  ;  it  was  thrown  into  transverse  folds,  and  the 
ileum  was  found  within  it.  The  caecum  and  ascending  colon  were  entirely 


Position  of  intestines  in  a  case  of  intussusception  of  csecum  and  ascending  colon  into  descending 
colon  and  sigmoid  flexure  ;  the  commencement  of  the  rectum  is  drawn  from  its  position,  to  show  the 
•translated  bowel  within. 

intruded.  The  rest  of  the  ileum  was  much  distended  ;  a  great  part  of  the 
jejunum,  however,  was  collapsed,  and  situated  behind  the  transverse  colon 
and  stomach,  in  the  position  described,  as  the  sac  of  the  lesser  omentum.  It 


INTUSSUSCEPTION.  451 

f  d\  \  F  f~  r~  f"i'~~  (~ir~Tt-cr*r~r\-f\ 

occupied  this  position  either  from  the  'congenital  looseness  of  the  Jcolon,  or 
from  its  meso-colon  having  been  drawft  askle  by  the  intnssuiSceptiOiF;  'tlitsr 
foramen  of  Winslow  was  normal.  The  general  peritoneum  was  intensely 
injected,  and  was  covered  with  lymph,  and  there  was  general  acute  perito- 
nitis ;  the  small  intestine,  however,  which  was  situated  behind  the  stomach, 
was  not  inflamed. 

The  stomach  contained  semi-feculent  fluid  ;  but  the  duodenum  was  normal. 
Several  lumbrici  were  found  in  the  jejunum  ;  the  ileum  presented  towards 
the  commencement  of  the  intussusception  an  ulcer  about  half  an  inch  in 
diameter,  much  congested  at  its  margin  ;  the  intestine  was  full  of  yellow  fluid 
feces.  On  tracing  the  intestine  onwards  the  lower  part  of  the  ileum,  the 
caecum  and  ascending  colon  were  found  in  the  descending  colon.  It  could  be 
felt  within  the  large  bowel,  and  readied  into  the  rectum,  within  a  few  inches 
of  the  anus.  On  opening  the  sigmoid  flexure  and  rectum,  the  termination 
of  the  intussuscepted  portion  was  observed,  almost  black,  but  surrounded  by 
semi-fluid  feces ;  the  apex  of  the  invaginated  portion  was  very  tense,  its 
opening,  which  would  admit  the  little  finger,  was  marked  by  a  fissure  towards 
one  side  on  account  of  the  contraction  of  the  mesentery.  Turning  aside  the 
bowel  it  was  found  to  be  convex  and  twisted  from  the  dragging  of  the  mesen- 
tery, and  at  the  concave  side  was  a  large  irregular  ulcer  at  the  most  tense 
portion.  In  the  sigmoid  flexure,  which  was  considerably  distended,  was  a 
small  opening  into  the  peritoneal  cavity,  which  has  set  up  general  peritonitis; 
at  the  other  extremity  of  the  intussuscepted  portion  the  finger  could  be  easily 
passed  round  the  bowel,  although  there  was  commencing  adhesion  for  the 
effusion  of  lymph.  The  liver,  spleen,  kidneys,  &c.,  were  healthy. 

This  case  was  one  of  peculiar  interest,  on  account  of  the  obscurity 
of  the  disease;  the  colic  appeared  to  be  due  to  the  lumbrici,  but  the 
severity  of  the  symptoms,  the  intense  pain,  the  purging  of  bloody 
mucus,  the  almost  incessant  vomiting,  and  the  distended  coils  of  in- 
testine, indicated  a  more  serious  abdominal  lesion.  The  disease  lasted 
eleven  weeks,  and  it  is  probable  that  the  intussusception  continued 
during  that  period,  at  first  perhaps  slight  in  extent,  but  gradually 
increasing  to  a  greater  degree.  The  canal  did  not  become  entirely 
occluded  till  near  the  fatal  termination  ;  and  it  is  possible  that  the  in- 
tussusception may  have  become  partially  restored  with  the  relief  of 
the  symptoms,  and  at  each  fresh  paroxysm  the  intestine  may  have 
been  pushed  further  onwards.  The  cause  of  death  was  peritonitis, 
consequent  on  rupture  of  the  sigmoid  flexure  ;  and  the  exciting  cause 
of  the  intussusception  was  probably  the  irregular  peristaltic  action 
consequent  on  the  lumbrici  associated  with  unusual  and  perhaps  con- 
genital freedom  of  the  caecal  mesentery.  As  far  as  can  be  judged  by 
a  post-mortem  consideration  of  treatment,  opium  was  the  most  de- 
sirable remedy,  with  rest,  bland  nutriment,  and  the  avoidance  of  any 
purgative  medicines.;  but  with  such  an  extensive  intrusion  of  intes- 
tine no  remedy  would  probably  have  been  effective;  the  injection  of 
fluid  at  an  early  period  might  have  been  effectual  in  reducing  the 
invaginated  bowel,  but  the  gangrenous  condition  of  the  inclosed 
bowel  had  a  reparative  tendency,  which  in  like  cases  has  often  re- 
sulted in  the  recovery  of  comparative  health. 

I  have  observed  instances  in  which  symptoms  very  similar  to  those 
manifested  in  this  case  have  gradually  subsided,  and  the  patient 


452          nO  INTUSSUSCEPTION. 


/v  <•!  0  *  T  i:  Pi  "-i.0    ^  L">  ^   I    !  IN  a       j  n  -r\     T< 

vered  ;  such  a  case  occurred  under  my  colleague,  Dr.  Fagge,  in 

,:  in'  'which  tlio  pstjHleiftti  tH^seqUently  died  from  a  twist  of  the 
bowel  at  the  point  where  an  old  intussusception  had  become  adhe- 
rent to  the  abdominal  wall.1 

CASE  CLIII.  Intussusception.  Recovery.  Ccecum  and  the  whole  of  the 
Ascending  Colon  passed  per  Rectum.  (See  Prep,  in  Guy's,  1875.)  —  W. 
P  —  ,  ait.  6,  a  patient  of  Mr.  C.  King's,  in  1852.  The  previous  health  of  the 
child  had  been  good,  till  he  was  attacked  with  oedema  and  discoloration  of 
both  legs;  these  symptoms  soon  subsided,  but  constant  vomiting  came  on, 
with  constipation  and  pain,  and  with  tenderness  of  the  abdomen,  particularly 
in  the  right  iliac  region  ;  these  urgent  symptoms  remained  for  four  days, 
when  convulsion  and  insensibility  ensued.  He  remained  in  this  condition  for 
twelve  hours,  apparently  dying  ;  on  the  two  following  days  he  was  a  little 
better;  the  vomiting  ceased,  but  constipation  continued  ;  during  the  next  four 
days  there  was  no  cliange.  Eleven  days  after  the  seizure,  and  five  days  after 
the  cessation  of  the  vomiting,  he  had  an  evacuation  from  the  bowels,  and  the 
caecum  with  the  vermiform  process  and  the  ascending  colon  were  discharged; 
when  passed,  the  cylinder  of  the  intestinal  slough  was  complete.  In  a  few 
days  the  leg  became  gangrenous,  and  was  removed  by  Mr.  Hilton.  The 
child  did  well,  and  completely  recovered. 

The  symptoms  of  colic,  in  this  as  in  the  previous  case,  were  very 
severe,  and  the  recovery  of  the  child  very  remarkable  after  the  re- 
moval of  the  whole  of  the  caecum  and  ascending  colon.  It  must 
also  be  noticed  that  constipation  of  an  insuperable  character  was  not 
one  of  the  earlier  symptoms;  there  was  evident  impairment  of  the 
general  health  of  the  child,  as  shown  by  the  oedema  and  discoloration 
of  the  legs,  followed  by  gangrene  ;  and  it  was  suggested  that  unwhole- 
some food,  as  ergotized  bread,  might  have  produced  the  disease.  In 
cerebral  irritation,  also,  we  find  a  disposition  to  irregular  peristaltic 
action  of  the  intestine,  and  frequently  after  death  from  hydrocepha- 
lus  numerous  portions  of  invaginated  intestine  are  observed  ;  here, 
however,  the  abdominal  symptoms  preceded  the  cerebral.  The  fol- 
lowing cases  present  several  points  of  great  interest  connected  with 
this  subject. 

An  emaciated  man,  set.  28,  under  the  care  of  Mr.  Benjamin  Phil- 
lips,2 had  been  resident  in  a  miasmatic  district.  He  had  suffered 
occasionally  for  weeks  from  an  obscure  affection  of  the  digestive  sys- 
tem ;  the  abdomen  was  hard  and  tympanitic;  there  was  frequent 
nausea,  but  vomiting  rarely  took  place  ;  the  alvine  evacuations  were 
sometimes  frequent  and  fluid,  at  other  times  they  were  natural; 
leeches  were  applied  to  the  abdomen  ;  the  diarrhoea  and  nausea  con- 
tinued, the  evacuations  became  greenish,  and  contained  blood  ;  and 
an  elongated  mass  was  found  occupying  the  left  iliac  fossa.  The  pa- 
tient had  a  constant  disposition  to  sleep  ;  and  he  died  seven  days  after 
coming  under  Mr.  Phillips's  care. 

1  The  seat  of  constriction  was  over  the  right  sacro-iliac  joint  ;  here  the  enormously 
distended  ileura  went  to  the  wall  of  the  abdomen,  and  became  lost  for  half  an  inch 
just  before  its  junction  with  the  caecum.  The  two  edges  of  bowel  thus  left,  on  open- 
ing the  intestine,  were  found  to  be  raised,  red,  and  well  defined,  and  a  seam  in  the 
mesentery  led  to  this  point. 

*  'Medical  Gazette.' 


INTUSSUSCEPTION.  453 

On  inspection  there  was  found  to  be  acute  peritonitis,  and  invagi- 
nation  of  the  caecum  and  ileum  into  the  transverse  and  descending 
colon.  Several  inches  of  the  invaginated  intestine  were  gangrenous, 
and  the  serous  surfaces  of  the  inclosed  bowel  were  adherent;  perfora- 
tion had  taken  place. 

In  another  case,  reported  by  the  same  gentleman,  the  patient,  set. 
31,  had  suffered  for  many  months;  the  skin  was  sallow;  he  was  ema- 
ciated, and  had  a  tympanitic  state  of  the  abdomen,  with  tenderness 
in  the  course  of  the  descending  colon  and  sigmoid  flexure.  In  the 
left  iliac  region  a  tumor  could  be  felt,  considered  by  some  to  be  im- 
pacted feces.  On  inspection  there  was  general  peritonitis,  the  caecum 
and  ascending  colon  were  not  visible,  and  a  cylindrical  tumor  was 
found  in  the  iliac  fossa;  "two  inches  of  the  small  intestine  had  pene- 
trated into  the  caecum;  this  turned  upon  itself,  and  was  then  introduced 
into  the  ascending  colon,  which  in  turn  had  passed  into  the  transverse 
colon,  and  all  these  parts  thus  disposed  had  reached  the  left  iliac 
fossa."  Several  perforations  had  taken  place. 

In  a  case  reported  by  Mr.  Jon.  Hutchinson,  in  the  'Pathological 
Transactions,'  the  symptoms  of  colic  had  existed  for  several  months, 
and  the  patient,  a  young  man,  had  sometimes  swung  himself  on  the 
steps  of  a  ladder,  as  the  only  means  of  relieving  the  pain.  The  in- 
vaginated portion  of  intestine  was  found  adherent,  and  the  appear- 
ances evidently  indicated  that  it  had  been  so  intruded  for  a  conside- 
rable period. 

CASE  CLIV.  Constipation.  Subsequent  Perforation.  Peritonitis.  In- 
tussusception Restored?  (From  the  Museum  of  Records.) — M.  S — ,  get.  60, 
ten  or  twelve  days  before  application  had  experienced  sudden  violent  pain  in 
the  abdomen,  with  constipation  :  vomiting  came  on,  but  no  hernia  could  be 
detected  ;  by  avoiding  medicine  the  vomiting  subsided.  A  dose  of  croton  oil 
produced  an  evacuation,  but  without  relief  to  the  symptoms  ;  the  bowels 
were  afterwards  moved  by  castor  oil ;  the  symptoms  of  peritonitis  returned, 
and  the  patient  quickly  died.  On  inspection  a  portion  of  small  intestine  was 
found,  dusky  and  lurid,  and  patches  of  lymph  were  observed  ;  on  moving  the 
intestines  feces  escaped.  The  discolored  portion  was  from  six  to  seven 
inches  in  length,  and  the  mucous  membrane  was  dark  ;  the  mesentery  was 
also  slightly  discolored,  and  greenish  at  that  part.  A  defined  line  marked 
the  diseased  portion. 

The  appearances  presented  in  this  case  were  either  those  of  an 
intussusception  restored,  which  was  the  opinion  of  one  who  had  had 
very  great  experience  in  pathology ;  or,  2dly,  of  internal  strangula- 
tion ;  or  3dly  of  local  enteritis,  as  we  have  previously  mentioned  in 
speaking  of  that  disease  ;  or,  4thly,  of  a  twist  of  the  intestine  on  the 
mesentery,  which  had  become  partially  restored.  The  last  sugges- 
tion was,  perhaps,  the  most  probable.  There  was  no  evidence  that 
either  external  or  internal  hernia  had  existed  ;  and  whilst  it  is  very 
probable  that  cases  of  intussusception  are  restored,  we  scarely  feel 
warranted  in  asserting  that  invagination  had  taken  place  in  this 
instance. 

The  following  case  is  a  remarkable  one,  as  indicating  one  of  the 
sequences  of  intussusception.  It  is  from  the  '  Medical  Gazette' : — 


454  INTUSSUSCEPTION. 

A  patient,  aet.  65,  had  constipation,  violent  pain  in  the  bowels,  and 
vomiting;  in  four  days  the  pain  ceased.  It  had  commenced  on 
August  the  26th  ;  on  the  31st  there  were  several  offensive  dejections, 
and  on  September  5th  forty -four  inches  of  intestine  were  evacuated. 
The  patient  survived  forty  days. 

On  inspection  the  sigmoid  flexure  was  wanting,  and  the  caecum 
and  colon,  seventeen  inches  in  length,  opened  into  a  large  fecal 
abscess,  into  which  the  rectum  passed. 

CASE  CLV.  Phthisis.  Intussusception  of  the  Ileum.  Peritonitis — 
James  H — ,  aet.  16,  a  pale  boy,  was  admitted  into  Guy's  Hospital,  May  23d, 
1860.  For  a  year  he  had  suffered  from  cough  and  phthisical  symptoms. 
Eight,  days  before  admission  he  complained  of  pain  in  the  abdomen,  which 
was  accompanied  with  vomiting.  The  pain  commenced  in  the  region  of  the 
caecum,  but  the  tenderness  was  at  first  slight ;  this  symptom  afterwards  in- 
creased, and  became  more  general  as  the  indications  of  peritonitis  were  de- 
veloped. There  was  great  restlessness,  and  persistent  bilious  vomiting.  The 
bowels  acted  once  after  injection,  but  there  was  no  discharge  of  blood. 
Death  took  place  on  June  1st. 

On  inspection,  phthisical  vomicae  were  found  at  the  apices  of  both  lungs  ; 
and  the  lower  lobe  of  the  left  lung  was  in  a  state  of  recent  hepatization.  In 
the  abdomen,  both  small  and  large  intestines  were  distended  ;  there  were 
some  lines  of  injection  at  the  margins  of  contact  between  the  intestinal  coils. 
A  foot  from  the  caecum  all  the  coats  of  the  small  intestine  had  sloughed 
through  up  to  the  mesentery ;  but  extravasation  had  not  taken  place  to  any 
great  extent,  although  no  adhesions  had  formed.  It  was  at  once  seen  that 
the  sloughing  had  arisen  from  intussusception  of  the  ileum  ;  and  several 
inches  of  separated  intestine  were  in  a  sloughy  state.  The  sigmoid  flexure 
and  the  parts  below  the  intussusception  were  not  collapsed,  but  were  partially 
distended  with  flatus. 

CASE  CLVI.  Intussusception  of  Ileum.  Perforation.  Peritonitis — John 
S — ,  aet.  17,  was  admitted  into  Guy's  Hospital,  under  Dr.  Barlow's  care, 
September  17th,  1857,  in  a  moribund  state,  and  died  in  an  hour  or  two.  It 
was  stated  that  he  had  suffered  from  insuperable  constipation  for  a  fortnight, 
with  increasing  distension  of  the  abdomen  and  vomiting.  The  first  symptom 
had  been  inaction  of  the  bowels  two  weeks  previously ;  and  after  that  time 
he  had  only  the  smallest  evacuation  after  injections.  On  admission  there 
was  peritonitis  and  fecal  vomiting.  The  body  was  that  of  a  strong,  muscular 
man  ;  the  abdomen  was  much  distended  and  tympanitic. 

On  inspection,  the  thoracic  viscera  were  found  to  be  healthy.  There  wras 
acute  peritonitis,  but  only  a  small  quantity  of  lymph  had  been  effused.  The 
small  intestines  were  much  distended,  but  the  large  were  contracted.  The 
obstruction  was  at  once  seen  to  be  an  intussusception  at  the  lower  part  of  the 
ileum  ;  and  upon  raising  this  portion  an  opening  was  seen  in  the  gut,  and 
fecal  matter  was  escaping ;  a  small  quantity  only  of  fecal  matter  was  at  first 
seen,  so  that  the  perforation  probably  remained  nearly  closed  by  being  in 
contact  with  an  adjoining  coil,  although  the  whole  calibre  of  the  intestine 
was  torn  through.  The  intussusception  was  found  to  be  at  three  feet  from 
the  caecum,  and  consisted  in  four  to  five  inches  of  the  ileum  which  had  passed 
into  a  lower  portion.  The  contained  part  was  in  a  state  of  slough,  and  was 
in  shreds,  as  if  it  would  soon  have  become  detached.  At  the  upper  orifice 
some  firm  adhesions  existed  between  the  serous  surfaces,  but  at  the  point  of 
constriction  these  had  separated.  The  opening  of  the  lower  part  was  almost 


INTUSSUSCEPTION.  455 

closed,  so  that  a  probe  could  be  scarcely  introduced.  The  serous  surfaces 
were  closely  adherent  at  the  margin,  where  they  passed  the  one  into  the 
other ;  and  upon  cutting  through  the  included  part  the  serous  surfaces  were 
seen  in  like  manner  to  be  connected  by  lymph  ;  and,  as  a  considerable  space 
existed,  the  lymph  uniting  them  was  of  some  thickness ;  the  interior  mucous 
passage  was  almost  closed,  only  just  admitting  a  probe.  All  the  small  intes- 
tines, as  well  as  the  stomach,  were  filled  with  fluid  fecal  matter,  which  in 
general  appearance  could  not  be  distinguished  from  that  in  the  colon. 

This  patient  was  dying  when  admitted,  and  there  were  no  symp- 
toms to  enable  us  to  distinguish  this  case  of  intussusception  from  one 
of  internal  strangulation  of  the  intestine.  It  is  possible  that,  had 
rest  been  enjoined  and  proper  treatment  adopted  from  the  first,  the 
contained  slough  might  have  been  discharged  without  the  separation 
of  those  adhesions  on  which  the  safety  of  the  patient  depended. 

CASE  CLVII.  Intussusception  of  Si y  moid  Flexure.  External  Protru- 
sion. Symptoms  of  Strangulation.  Peritonitis.  Death — Catharine  F — , 
a;t.  25,  was  admitted  into  Guy's  Hospital,  June  18th,  1857,  and  died  on  the 
28th.  She  was  a  single  woman,  and  in  the  October  before  her  death  began 
to  suffer  from  prolapse  of  the  anus  ;  the  prolapse  was  returned,  but  again 
came  down,  and  from  mistaken  modesty  she  had  neglected  her  complaint. 
Three  weeks  before  admission  the  bowel  came  down,  and  she  was  unable  to 
return  it,  and  at  the  same  time  constipation  ensued.  Still  no  advice  was 
sought,  and  on  admission  she  was  found  to  suffer  from  strangulation  ;  the 
bowels  had  not  been  moved  for  three  weeks.  The  intussuscepted  bowel  lay 
for  several  inches  outside  the  anus,  but  could  be  easily  replaced,  although  the 
strangulation  was  not  thereby  overcome. 

She  died  on  the  28th,  ten  days  after  entering  the  hospital.  The  body  was 
spare ;  the  abdomen  was  tynipanitic,  but  not  excessively  distended.  There 
was  acute  general  peritonitis.  All  the  intestines  were  slightly  distended,  and 
full  of  fluid  feces.  Nothing  abnormal  was  found  till  the  pelvis  was  ex- 
amined, where,  low  down  behind  the  uterus,  an  intussusception  was  found, 
and  at  first  it  seemed  so  near  to  the  anus  as  to  be  merely  a  prolapse  ;  when, 
however,  the  intestine  was  removed  it  was  found  that  the  proximity  to  the 
anus  arose  from  dragging  down  of  the  intestine,  for  when  stretched  out  the 
invaginated  part  did  not  reach  the  anus  by  three  inches  ;  measuring  from  the 
line  of  constriction  to  the  anus  was  nine  inches,  and  the  invaginated  part 
measured  half  this  length,  making  the  commencement  of  the  inverted  bowel 
eighteen  inches  from  the  anus,  and  therefore  in  the  sigmoid  flexure.  The 
invaginated  part  was  sloughing,  and,  as  usual,  slightly  curved  on  itself  by 
the  dragging  of  its  attachment.  The  other  viscera  were  healthy. 

These  instances  of  intussusception  present  us  with  symptoms  of 
severe  colic,  with  vomiting  and  constipation,  and  often  with  tumor; 
2dly,  they  show  that  the  pain  and  other  symptoms  are  often  parox- 
ysmal; 3dly,  that  the  constipation  is  not  always  constant,  but  on  the 
contrary,  that  diarrhoea  is  sometimes  present;  4thly,  that  the  dis- 
charge of  blood  and  mucus  occasionally  takes  place;  5thly,  that  the 
causes  of  death  are  perforation  and  acute  peritonitis,  or  secondary 
fecal  abscess;  and  6thly,  that  the  disease  is  cured  by  restoration  of 
the  parts,  and  sometimes  by  sloughing  and  separation  of  the  invagi- 
nated portion. 


456  CANCEROUS    DISEASE. 


CASES  OF  CANCEROUS  DISEASE. 

CASE  CLVIII.  Columnar  Epithelioma  of  the  Sigmoid  Flexure,  with 
Cancerous  Infiltration  of  Glands  near  the  Gall-bladder — Ralph  G — ,  get. 
44,  a  stout,  plethoric  man,  who  had  served  for  fifteen  years  in  the  police 
force,  had  been  employed  at  the  station  house,  so  that  his  life  was  a  seden- 
tary one.  He  had  had  good  health,  with  the  exception  of  slight  attacks  of 
rheumatism,  till  one  year  before  admission,  when,  after  taking  less  than  his 
usual  exercise,  his  bowels  became  confined ;  he  had,  however,  generally  a 
motion  every  three  days. 

He  was  admitted  into  the  hospital,  under  my  care,  July  3d. 

On  June  20th  he  passed  a  solid  stool,  small  in  quantity,  but  without  strain- 
ing or  pain  ;  from  that  time  nothing  had  been  passed.  He  did  not  feel  any 
uneasiness  till  the  23d,  when  he  felt  pain  and  a  sense  of  weight  in  his  abdo- 
men, and  he  vomited  slightly.  These  symptoms  passed  off,  but  afterwards 
returned.  He  had  hiccough  at  night,  and  his  sleep  had  been  disturbed  ;  the 
appetite  had  failed,  his  abdomen  had  swelled",  and  he  had  some  dyspncea. 
Before  admission  he  took  various  aperients,  and  had  an  injection  of  turpen- 
tine, but  without  effect. 

July  3d.  The  abdomen  was  much  swollen,  measuring  forty  and  a  half 
inches  in  crcumference ;  it  was  most  prominent  in  the  position  of  the  trans- 
verse colon,  and  tympanitic.  This  tympanitic  resonance  could  be  traced  in 
the  course  of  the  colon,  nearly  to  the  sigmoid  flexure.  At  that  part  he  had 
slight  pain,  and  stated  that  some  months  before  he  had  had  a  similar  attack. 
He  had  not  had  any  discharge  of  blood,  mucus,  nor  of  air,  per  rectum;  there 
was  no  pain  on  manipulating  the  abdomen,  nor  any  increase  of  temperature; 
the  pulse  was  quick  and  sharp,  98  ;  the  respiration  was  accelerated,  the  skin 
was  perspiring,  the  tongue  had  a  white  fur  upon  it.  A  turpentine  enema  was 
ordered  at  once,  and  the  soap  and  opium  pill,  gr.  v,  three  times  a  day. 

4th. — Vomiting  took  place  at  5  A.M.,  the  pulse  was  strong,  86;  the  skin 
cool  ;  he  had  had  no  vomiting  since  the  morning.  The  pills  were  continued, 
and  he  was  to  have  a  rue  injection. 

5th — He  passed  a  considerable  evacuation  and  felt  much  easier.  He  after- 
wards had  some  sleep,  and  was  able  to  take  some  food  ;  the  pulse  was  feeble, 
116;  tongue  more  brown.  9  P.  M — Calomel  gr.  xij,  were  ordered  to  be 
taken,  and  the  rue  injection  to  be  repeated. 

6th — Passed  a  small  quantity  of  faeces.  The  prostration  of  strength  and 
tymranitic  distension  increased;  there  was  no  further  action  of  the  bowels, 
although  the  long  tube  was  used  ;  the  patient  became  restless,  the  pulse  rapid, 
but  he  did  not  suffer  from  severe  vomiting.  Opium  was  continued.  The 
urine  was  moderate  in  quantity  and  high  colored. 

2  P.  M — Mr.  Birkett  could  not  detect  anything  on  examination  per  rec- 
tum, and  did  not  think  the  symptoms  of  insuperable  obstruction  sufficiently 
severe  to  warrant  surgical  interference. 

9  P.M — The  patient  appeared  in  the  same  condition  as  in  the  morning, 
he  was  prostrate  and  was  covered  with  clammy  perspiration.  The  patient 
gradually  sank,  and  died  2.30  A.M.  on  the  8th,  nineteen  days  after  the  com- 
mencement of  the  symptoms  of  obstruction. 

Inspection  twelve  hours  after  death.  The  rigor  mortis  was  well  marked. 
The  abdominal  parietes  contained  a  considerable  layer  of  integiimental  fat. 
The  abdomen  measured  round  the  umbilicus  three  and  a  half  feet.  On  opening 
the  peritoneal  cavity  it  was  found  to  contain  about  three  pints  of  opaque 
serum  mixed  with  shreds  of  lymph  ;  the  peritoneum  was  much  injected,  and 
was  covered  with  spots  of  lymph.  Both  small  and  large  intestines  were 


CANCEROUS    DISEASE.  457 

enormously  distended  ;  this  was  especially  marked  in  the  caecum  and  colon,  as 
far  as  the  sigmoid  flexure,  where  was  the  seat  of  obstruction ;  the  sigmoid 
flexure  was  distended  and  bound  to  the  walls  of  the  abdomen,  the  intestine 
then  turned  inwards  towards  the  promontory  of  the  sacrum,  where  it  became 
suddenly  narrow  at  its  union  with  the  rectum.  Externally  the  constricted 
mass  felt  hard,  and  after  removal  it  was  found  that  an  ordinary  probe  would 
scarcely  pass.  The  obstruction  was  nearly  an  inch  in  length  ;  on  placing  it 
in  water  the  surface  was  quite  flocculent,  resembling  villous  cancer.  The 
intestine,  both  above  and  below,  was  healthy;  above,  was  a  large  quantity  of 
fluid  feces  ;  below,  small  scybalous  masses.  Near  the  gall-bladder  were 
several  glands  infiltrated  with  cancerous  product.  The  other  organs  were 
healthy. 

The  microscopical  examination  of  the  diseased  growth  presented 
cells  resembling  columnar  epithelium,  but  of  greater  size,  and  con- 
taining large  nuclei.  The  whole  of  the  flocculent  surface  was  com- 
posed of  cells  of  this  kind,  but  no  large  cells,  such  as  are  usually 
found  in  epithelial  cancer,  were  observed.  They  appeared  rather  to 
be  modified  columnar  epithelium.  The  muscular  coat  of  the  intes- 
tine at  that  part  was  much  contracted.  The  diagnosis  in  this  case 
was  from  the  first  clear ;  the  gradually  increasing  constipation,  ab- 
sence of  pain,  resonance,  so  far  as  the  sigmoid  flexure,  with  previous 
slight  pain  at  that  part,  and  the  normal  quantity  of  urine,  all  tended 
to  show  that  the  obstruction  was  at  or  about  the  sigmoid  flexure. 
It  was  a  matter  of  regret  that,  in  a  case  so  favorable  for  surgical 
assistance,  such  means  were  postponed  till  fatal  peritonitis  came  on ; 
but  the  apparent  mildness  of  the  symptoms,  the  absence  of  vomiting, 
on  account  of  the  non -administration  of  drastic  purgatives,  led  some 
to  the  supposition  that  the  disease  arose  rather  from  impacted  feces 
than  from  an  insuperable  obstruction.  The  development  of  glands 
infiltrated  with  cancer  near  the  gall-bladder  was  an  interesting  fact 
with  this  form  of  disease,  which  appeared  to  be  of  the  character  of 
epithelial  cancer,  in  which  there  is  less  tendency  to  glandular  infil- 
tration. 

CASE  CLIX.  Cancer  of  the  Sigmoid  Flexure.  Perforation — Sarah 
O — ,  set.  42,  was  admitted  November  18th,  1856,  and  died  the  following  day, 
at  8  A.  M.  In  July  she  had  received  a  fall,  and  on  August  5th  experienced 
pain  in  the  region  of  the  sigmoid  flexure  of  the  colon.  The  pain  gradually 
extended  over  the  whole  abdomen ;  injections  were  administered  which  pro- 
duced evacuations  from  the  bowels,  several  days  before  admission. 

AVhen  brought  to  Guy's  Hospital  she  was  too  ill  to  give  any  definite  state- 
ment in  reference  to  herself.  The  countenance  was  anxious,  the  pulse  was 
small  and  compressible.  The  abdomen  was  very  much  distended,  and  when 
exposed  the  position  of  the  transverse  colon  was  more  prominent  than  other 
parts,  and  was  tympanitic.  The  pain  and  tenderness  were  general ;  vomiting 
was  very  distressing  ;  an  abundant  quantity  of  urine  was  passed.  Opium  was 
given,  and  a  warm  poultice  was  applied  ;  but  she  died  the  following  morning. 

Inspection  was  made  about  six  hours  after  death.  The  thoracic  viscera 
were  quite  healthy.  The  peritoneum  was  much  injected,  and  the  intestines 
appeared  dry,  from  a  delicate  stratum  of  lymph  upon  them. 

The  colon  was  very  much  distended  as  far  as  the  sigmoid  flexure  ;  the  small 
intestines  also  were  moderately  distended.  The  stomach  was  healthy.  Near 


458  CANCEROUS    DISEASE. 

the  end  of  the  ileum  there  was  considerable  congestion  and  several  ulcers ; 
these  ulcers,  however,  were  much  more  extensive  in  the  crccum.  The  caecum 
was  enormously  enlarged,  and  there  was  very  general  transverse  ulceration, 
exposing  the  circular  muscular  fibres,  as  if  ulcerated  from  over-distension; 
in  some  parts  the  muscular  coat  also  was  destroyed,  and  slight  perforation  had 
taken  place  in  one  spot,  but  without  extravasation  of  feces  ;  the  gut  was  more 
than  nine  inches  in  circumference.  The  appendix  was  filled  with  mucus, 
which  was  very  slightly  acid ;  and  it  was  adherent  in  the  long  axis  of  the 
colon.  The  descending  colon  was  very  much  distended  as  far  as  the  brim  of 
the  pelvis,  where  it  became  suddenly  contracted  ;  and  this  part  was  adherent 
to  the  uterus  and  to  a  coil  of  small  intestine.  On  separation  the  intestine 
was  found  to  be  drawn  in  at  that  part,  and  hardened.  On  opening  it,  the 
little  finger  could  be  passed,  and  the  canal  above  was  filled  with  fluid  feces ; 
at  the  constriction  there  were  vascular  prominent  growths,  corresponding 
almost  to  the  position  of  the  longitudinal  bands  ;  the  section  had  a  yellowish 
color,  and  showed  that  both  the  muscular  and  mucous  coat  were  involved. 
On  careful  microscopical  examination  the  surface  was  found  to  present  a  few 
villous  processes,  and  the  mass  consisted  of  abundant  nuclei  and  many  com- 
pound nucleated  cells,  resembling  some  forms  of  medullary  cancer  ;  above  the 
constriction  was  a  smooth  round  opening,  extending  through  the  coats  of  the 
intestine  into  the  peritoneum,  but  adhesions  had  formed  between  the  uterus 
and  coils  of  small  intestine,  so  as  to  prevent  extravasation.  The  constriction 
was  seventeen  inches  from  the  anus ;  below  the  stricture  was  some  dry  fecal 
matter.  The  other  abdominal  viscera  and  glands  were  healthy. 

CASE  CLX.  Cancerous  Disease  of  the  Sigmoid  Flexure.  Ecchymosis  of 
Stomach.  Ulceration  of  the  Ileum.  Contracted  Mitral  Valve. — Ellen  II — , 
set.  53,  was  admitted  November  7,  1855.  She  was  a  married  woman,  with- 
out family ;  she  had  been  living  at  Shepherd's  Bush,  and  was  greatly  ema- 
ciated. 

Seven  months  before  admission  she  had  had  severe  pain  at  the  lower  part  of 
the  abdomen,  and  was  compelled  to  desist  from  work ;  the  pain  came  on  four 
or  five  times  a  day  ;  the  bowels  were  confined,  but  had  previously  been  regular. 
The  motions  were  then  very  scanty,  except  after  injections ;  she  had  some- 
times had  severe  vomiting,  and  at  times  offensive  matter  was  rejected  ;  the 
urine  had  always  been  abundant. 

The  abdomen  on  admission  was  very  large  and  tympanitic,  but  it  was  most 
prominent  in  the  umbilical  region ;  the  tongue  was  clean ;  the  pulse  WHS 
small  and  very  compressible.  No  abdominal  tumor  could  be  felt ;  and  there 
was  no  tenderness.  On  admission  enemata  were  administered,  and  purga- 
tives, which  latter  aggravated  the  symptoms.  November  24th,  opium  was 
given,  gr.  j  every  six  hours.  This  was  followed  by  marked  improvement, 
the  stomach  became  quiet,  and  she  was  able  to  retain  food. 

November  30th — She  was  not  so  well,  and  complained  of  severe  pain  in 
the  stomach  ;  the  tongue  was  small  and  contracted  ;  the  bowels  were  opened 
freely;  enemata  had  been  administered,  and  opium  given. 

December  19th — She  was  much  better  ;  the  abdomen  was  supple,  not  dis- 
tended ;  and  the  bowels  were  open  ;  she  was  free  from  pain,  and  had  a  good 
appetite ;  she  took  some  porter  and  a  chop,  and  wine.  Opium  gr.  j  was  con- 
tinued. The  bowels  afterwards  again  became  constipated  ;  the  abdomen  be- 
came painful,  and  the  strength  failed.  She  sank  on  January  8th. 

January  9th — Inspection,  2.30  P.  M.,  seventeen  hours  after  death.  The 
body  was  extremely  emaciated  ;  the  eyes  were  sunken  ;  the  abdomen  was 
greatly  distended.  The  parietes  of  the  abdomen  were  thin.  On  opening  the 


CANCEROUS    DISEASE. 


459 


peritoneal  cavity,  an  enormously  distended  transverse  colon  was  found  to 
occupy  the  whole  anterior  region  of  the  abdomen  ;  from  the  liver  it  passed 
down  to  the  brim  of  the  pelvis,  then  ascended  nearly  to  the  scrobiculus  cordis, 
before  it  formed  a  second  smaller  curve,  and  became  the  descending  colon. 
The  large  intestine  was  distended  as  far  the  termination  of  the  sigmoid  flex- 
ure. Along  the  margins  of  the  dis- 
tended coils  of  intestine  were  lines  of 
injection,  and  between  some  of  the  foils 
were  delicate  flakes  of  lymph.  At  the 
commencement  of  the  rectum  the  in- 
testine was  contracted  ;  and  a  drawing 
in  of  the  coats  of  the  intestine  gave  the 
part  an  irregularly  puckered  appear- 
ance ;  although  thus  contracted,  the 
intestine  at  that  part  was  readily  mov- 
able. The  whole  of  the  colon  was  dis- 
tended with  fluid  bilious  feces  ;  at  the 
constricted  part  the  intestine  would 
only  admit  an  ordinary  quill ;  the  con- 
striction was  one  inch  in  breadth, 
raised,  nodular,  and  deeply  injected ; 
the  superficial  portion  was  soft,  and  of 
a  grayish  color ;  this  rested  on  firm  iron 
gray  structure,  and  minute  masses  of 
yellowish  fat ;  the  muscular  coat  was 
drawn  in  and  lost  at  this  part ;  but  in 
the  colon,  both  above  and  below  the 
stricture,  it  was  distinct. 

On  careful  examination  of  this  part 
the  surface  was  smooth,  and  presented 
columnar  epithelium,  nucleated  cells, 
and  elongated  nuclei  (a)  ;  beneath  the 
mucous  membrane,  which  was  itself 
dense,  changed  in  character  and 
fibrous,  was  a  considerable  quantity  of 
firm,  fibrous  tissue,  arranged  at  right 
angles  with  the  intestine  (6),  and  leav- 
ing interspaces  filled  with  nuclei,  but 
without  nucleoli  (e) ;  still  deeper,  mus- 
cular fibre  could  be  detected.  There 
was  no  structure  of  an  ordinary  carci- 
nomatous  character.  The  nuclei  were  diiferent  from  ordinary  nuclei,  not 
having  well-defined  cell-wall  or  nucleoli.  They  appear  like  a  coagulated 
blastema,  in  course  of  development  into  a  fibrous  structure. 

In  the  termination  of  the  ileum  was  an  ulcer  affecting  nearly  the  whole  of 
one  of  Peyer's  patches,  and  the  mucous  membrane  was  entirely  destroyed, 
but  the  disease  was  of  a  different  character  from  that  in  the  colon ;  the  rest 
of  the  small  intestine  was  healthy.  The  stomach  contained  some  black  mucus 
adherent  to  the  membrane.  At  the  cardiac  extremity  was  a  raised,  black 
patch,  covered  with  white  substance,  but  merely  affecting  the  mucous  mem- 
brane, probably  from  thrombosis.  The  follicles  were  evident,  and  slightly 
blackened  from  the  blood  which  they  contained;  but  at  the  upper  part  of  the 
membrane,  where  the  capillaries  were  more  numerous,  there  was  an  almost 
uniform  black  color ;  it  appeared  that  before  death  ecchymosis  had  taken  place 


4.OQ 


Obstruction  of  the  sigmoid  flexure  by  cancer- 
ous growth  ;  (a)  columnar  epithelium  and  nu- 
clei ;  (b)  fibrous  tissue  beneath  the  mucous 
membrane;  (e)  interspaces  filled  with  nuclei; 
(c)  surface  of  mucous  membrane  composed  of 
dense  fibre  tissue. 


460  CANCEROUS    DISEASE. 

from  the  capillaries,  and  that  after  death  the  blood  had  become  changed  by 
the  action  of  the  gastric  juice.  At  the  lesser  curvature  was  another  black 
patch,  but  without  the  white  substance  on  the  surface ;  there,  too,  tLe  follicles 
•were  beautifully  distinct,  some  being  marked  out  by  being  filled  with  changed 
blood ;  and  that  which  had  exuded  from  the  superficial  capillaries  was  black- 
ened. The  white  substance  consisted  of  cells  and  crystals.  There  was  con- 
traction of  the  mitral  valve ;  but  the  liver,  kidneys,  and  other  viscera  and 

glands  were  healthy. 

• 

In  this  case  the  obstruction  was  diagnosed  to  be  at  the  sigmoid 
flexure,  but  the  general  emaciation  led  to  the  belief  that  there  was 
more  general  infiltration  of  the  glands.  This  was  not  the  case,  but  the 
distension  had  produced  ulceration  of  the  ileum  ;  nutrition  was  much 
impaired,  and  the  diseased  condition  of  the  mitral  valve  interfered 
with  the  healthy  action  of  the  heart.  The  opium  acted  well,  and  its 
use  was  followed  by  marked  improvement,  and  by  action  from  the 
bowels ;  the  administration  of  purgatives  increased  the  vomiting  and 
prostration. 

CASE  CLXI.  Cancer  of  the  Liver,  of  the  Lumbar  Glands,  and  of  the 
Sigmoid  Flexure — Robert  W — ,  aet.  32,  was  admitted  September  19th,  and 
died  October  16th.  He  was  a  patten  maker,  and  had  lived  in  the  Borough. 
Four  months  previously  he  had  begun  to  feel  pain ;  there  were  symptoms  of 
indigestion,  and  afterwards  severe  pain  in  the  right  side.  He  became  ema- 
ciated, but  the  abdomen  was  enlarged ;  the  liver  could  be  felt  very  distinctly 
on  the  right  side,  and  nearly  reached  to  the  crest  of  the  ilium.  The  pain  in 
the  right  side  and  across  the  abdomen  became  more  severe,  and  he  gradually 
sank.  There  was  no  indication  of  disease  of  the  sigmoid  flexure  observed 
during  life. 

Inspection  was  made  twenty-seven  hours  after  death — The  body  was  spare, 
and  slightly  jaundiced.  The  chest  was  healthy,  with  the  exception  of  the 
base  of  the  right  lung,  where  was  a  large  patch  about  three  inches  in  diameter, 
white  in  color,  situated  on  the  surface  of  the  pleura,  and  about  one-eighth  of 
an  inch  in  thickness;  this  consisted  of  cancer,  extending  through  the  dia- 
phragm from  the  liver;  there  were  a  few  tubercles  in  the  neighborhood;  and 
one  of  the  glands  of  the  neck  was  infiltrated  with  cancer.  The  lungs, 
bronchial  glands  and  heart  were  healthy. 

Abdomen — The  peritoneum  contained  about  three  pints  of  serum  and  pus; 
the  liver  was  9^  Ibs.  in  weight,  and  towards  the  diaphragm  had  the  appearance 
of  a  large  abscess ;  the  surface  was  irregularly  contracted  from  the  develop- 
ment of  masses  of  cancer.  On  section,  nearly  the  whole  gland  was  found  to 
be  involved,  with  scarcely  any  intervening  gland  structure ;  and  these  can- 
cerous masses  presented  nearly  every  stage  of  degeneration ;  some  had  a  soft, 
yellow  centre,  others  a  dark  green  slough,  and  in  some  the  centre  was  semi- 
fluid. The  lumbar  glands  were  infiltrated;  and  at  the  termination  of  the 
sigmoid  flexure  was  a  small  fecal  abscess;  the  walls  of  the  intestine  were 
ulcerated,  broken  down,  and  infiltrated  with  cancer,  and  some  of  the  contents 
had  become  extravasated  among  the  cancerous  exudation. 

Here  there  was  no  marked  constipation  ;  the  cancer  was  medullary 
rather  than  scirrhous  or  epithelial ;  there  had  been  some  pain  in  the 
part,  but  no  obstruction.  The  patient  was  evidently  wasting  from 
organic  disease ;  the  liver  was  known  to  be  affected,  and  so  slight 
were  the  symptoms  of  disease  at  the  sigmoid  flexure,  that  they  were 


CANCEROUS    DISEASE.  461 

scarcely  noticed,  although  it  is  probable  that  the  disease  commenced 
at  that  part. 

CASE  CLXII.  Cancerous  Ulceration  of  the  Sigmoid  Flexure  of  the  Colon. 
Constipation — For  the  particulars  of  the  following  case  I  am  indebted  to  my 
friend  Sir  W.  Gull.  The  preparation  is  in  the  Museum  at  Guy's  (185435). 

Mrs.  H — ,set.  60,  in  May,  1854,  had  an  attack  of  diarrhoea,  and  a  similar 
attack  had  occurred  some  months  previously;  from  that  time  she  had  been 
troubled  with  flatulence  and  pain  in  the  abdomen.  The  diarrhoea  was  re- 
lieved, but  the  pain  continued.  On  July  the  22d  she  had  constipation,  which 
was  not  removed  by  the  use  of  castor  oil,  rhubarb,  &c.  There  was  no  vomit- 
ing,  the  pulse  was  quiet  and  the  tongue  clean.  Vomiting  came  on,  on  the 
24th.  The  examination  of  the  rectum  discovered  a  hard  mass  high  up  in  the 
recto-vaginal  space.  Opium  and  ice  removed  the  symptoms.  After  five  days 
the  bowels  were  relieved,  and  she  then  went  on  very  well  till  September  20th, 
when  the  bowels  again  became  obstructed ;  enemata  were  used,  and  opium 
was  administered;  croton  oil  was  rubbed  into  the  abdomen.  Purgatives  were 
occasionally  given,  but  in  vain;  after  five  weeks  of  complete  constipation, 
symptoms  of  peritonitis  came  on,  and  she  died.  The  operation  of  opening 
the  descending  colon  was  proposed,  but  the  patient  would  not  consent. 

In  this  case  diarrhoea  alternated  with  constipation,  a  condition 
which  is  not  unfrequent  in  disease  of  the  sigmoid  flexure. 

CASE  CLXIII.  Cancer  of  the  Sigmoid  Flexure.  Obstruction.  Relieved. 
Gradual  Exhaustion — Richard  C — ,  set.  32,  was  admitted  under  Sir  W. 
Gull's  care,  July  2d,  1854,  and  died  September  3d.  He  had  been  troubled 
with  symptoms  of  obstruction  for  five  months,  his  abdomen  often  becoming 
distended,  and  again  diminishing  after  escape  of  flatus.  Various  remedies 
were  given,  and  with  considerable  success  (quinine  and  opium).  The  bowels 
became  freely  acted  upon,  but  the  patient  became  gradually  wasted,  and  at 
last  sank. 

Inspection,  twenty  hours  after  death.  The  heart  and  lungs  were  healthy. 
The  abdomen  was  enormously  distended  on  account  of  the  size  of  the  large 
intestine;  the  omentum  was  drawn  upwards.  The  small  intestine  was  much 
enlarged ;  but  the  caecum  and  colon  were  enormously  so.  Just  within  the 
hollow  of  the  sacrum  was  the  constriction,  which  could  be  felt  as  a  hard 
lump  about  the  size  of  a  hen's  egg.  The  disease  occupied  four  inches  of  the 
canal,  and  consisted  of  epithelial  cancer.  The  walls  were  much  thickened, 
and  in  the  cellular  tissue  around  was  hard  tissue  of  a  scirrhous  character. 
The  interior  of  the  gut  was  ulcerated,  and  upon  it  were  a  few  vascular 
fringes.  The  mesentery  contained  a  few  hardened  glands.  The  walls  of  the  in- 
testine were  considerably  hypertrophied.  The  remaining  viscera  were  healthy. 

This  case  was  an  exceedingly  interesting  one,  showing  the  benefi- 
cial and  marked  effect  produced  by  judicious  treatment.  On  admis- 
sion there  appeared  but  little  probability  that  the  obstruction  would 
be  overcome;  the  opium  which  was  administered  with  quinine,  so 
far  allayed  the  intestinal  action  and  spasmodic  contraction,  that  feces 
slowly  passed  the  stricture,  and  for  a  time  there  appeared  probability 
of  recovery. 

CASE  CLXIV.  Colloid  Cancer  of  the  Sigmoid  Flexure.  Artificial  Anus 
in  the  Groin.  Pleuro-pneumonia — Thomas  C — ,  ast.  56,  had  had  severe 
pain  in  the  course  of  the  ureter,  and  it  was  supposed  that  he  had  renal  calcu- 


462 


CANCEROUS    DISEASE. 


lus.  On  admission  it  WHS  evident  that  there  was  an  abscess  forming  in  the 
iliae  region ;  this  reached  slowly  below  Poupart's  ligament,  and  was  allowed 
to  open  itself.  The  patient  became  more  and  more  prostrate,  and  a  few 
days  before  death  troublesome  diarrhoea  came  on. 

The  inspection  was  made  seven  hours  after  death.  The  body  was  rigid 
and  much  emaciated;  on  the  left  side,  below  Pou part's  ligament,  and  at  the 
crest  of  the  ilium,  were  two  openings  about  a  quarter  of  an  inch  in  diameter, 
the  surrounding  skin  being  thin  and  red;  a  probe  passed  for  several  inches 
along  the  course  of  the  crest  of  the  ilium,  and  a  discharge  of  feculent  pus 
proceeded  from  the  wound.  There  was  pneumonia  at  the  base  of  the  left 
lung.  The  heart  only  weighed  seven  ounces,  the  valves  were  atheromatous, 
and  the  muscle  fatty. 

Abdomen — The  parietes  were  rigid;  the  intestines  were  collapsed;  two 
bands  of  omentum  were  adherent  at  the  sigmoid  flexure.  The  stomach  was 
low  down,  and  much  distended;  its  mucous  membrane  was  mammillated ; 
the  secreting  cells  were  granular;  the  pylorus  was  healthy.  The  mucous 


Colloid  cancer  of  the  sigmoid  flexure  X  40°  diam.  ;  (a  6)  columnar  epithelium;  (c)  nuclei  with 
granular  blastema ;  (d)  large  cells,  with  large  nuclei,  and  some  with  several  nuclei  in  them;  (e) 
intervening  delicate  tissue  ;  (/)  elongated  fibre  cells. 

membrane  of  the  cascum  and  colon  were  of  a  gray  color.  The  colon  was 
contracted ;  at  the  commencement  of  the  sigmoid  flexure  was  a  hard  mass 
resembling  scybala;  on  opening  this  the  calibre  of  the  intestine  was  almost 
obliterated  by  an  irregular  growth  from  the  mucous  membrane,  which  in- 


CANCEROUS    DISEASE.  463 

volved  the  whole  circumference  of  the  gut,  and  would  only  admit  the  little 
finger  at  the  upper  margin ;  it  was  rounded,  foliated,  and  extended  in  one 
part  an  inch  up  the  descending  colon ;  the  lower  margin  was  of  the  same 
kind,  but  more  intensely  congested.  The  In-eadth  of  this  diseased  portion 
was  from  one  to  three  inches;  the  intermediate  part  was  ulcerated,  and  a 
communication  passed  at  the  posterior  part  into  an  irregular  sinus,  behind 
the  fascia  covering  the  quadratus  lumborum ;  this  sinus  was  filled  with  fecu- 
lent pus,  and  burrowed  downwards  along  the  crest  of  the  ilium  to  the  open- 
ings in  the  skin.  On  making  a  section  of  the  growth,  it  was  found  to  be  soft, 
of  a  yellowish-white  color,  and  had  a  striated  appearance,  and  fluid  could  be 
compressed  from  it;  several  parts  presented  transparent  gelatinous  masses  of 
colloid  cancer.  The  whole  of  the  mucous  and  muscular  coats  were  involved 
and  destroyed ;  and  the  muscular  tissue  of  the  quadratus  lumborum  was  filled 
with  round  isolated  masses  of  colloid  growth,  separated  by  bands  of  muscular 
fibre.  The  surface  of  the  growth  presented  columnar  epithelium,  some  cells 
of  normal  size,  others  much  enlarged  («  b)  and  containing  single  or  double 
nuclei;  some  of  these  cells  were  oblong;  the  principal  portion,  however,  of 
the  growth  was  composed  of  large  nuclei,  about  1000th  to  1500th  of  an  inch 
in  diameter,  with  distinct  nucleoli,  and  closely  packed  together  with  very  little 
intervening  blastema  (c) ;  there  were  some  large  cells  containing  several 
nuclei  (d).  On  the  field  were  numerous  masses  resembling  inflammatory 
granule  cells  (e).  The  intervening  tissue  consisted  of  delicate  fibres,  arranged 
so  as  to  form  cells  (e) ;  and  in  some  parts  presenting  elongated  cells  (f). 
There  was  no  doubt  as  to  its  cancerous  character;  and  there  were  a  few 
small  infiltrated  glands  in  the  neighborhood  of  the  cancerous  growth.  On 
the  surface  of  the  liver,  both  on  the  right  and  left  lobes,  the  peritoneum  was 
thickened  from  attrition ;  the  liver  was  fatty  and  coarse.  The  spleen  Avas 
soft,  its  corpuscles  were  visible.  The  kidneys  were  atrophied,  and  contained 
a  few  cysts ;  they  were  8^  oz.  in  weight. 

In  this  case,  the  examination  of  the  feces  or  the  discharge  might 
have  detected  cancer,  but  no  tumor  could  be  felt;  there  was  no  marked 
constipation,  but  pain  in  the  course  of  the  ureter  was  the  principal 
symptom. 

CASE  CLXV.  Cancerous  Disease  of  the  Sigmoid  Flexure.  Diarrhoea. 

Perforation.  Fecal  Abscess Elizabeth  S — ,  aet.  55,  was  admitted  into 

Guy's  Hospital,  March  29th,  1854.  She  was  a  married  woman,  but  had  had 
no  children.  She  was  much  emaciated,  and  for  three  years  had  ceased  to 
menstruate.  On  admission  she  had  a  hot  and  dry  skin ;  the  abdomen  was 
tender ;  the  pulse  was  sharp  and  frequent.  She  had  had  pain  in  the  hypo- 
gastric  region,  with  vomiting  and  purging,  and  the  stools  had  contained 
blood.  The  diarrhoea  became  more  severe,  and  there  was  increased  tender- 
ness and  pain  at  the  lower  part  of  the  abdomen  ;  the  evacuations  contained 
inflammatory  product.  She  died  on  May  16th,  severe  purging  having  con- 
tinued. 

On  inspection  the  lungs  and  heart  were  found  healthy.  A  cancerous 
growth  was  situated  above  the  sigmoid  flexure ;  and  there  was  ulceration  of 
the  new  growth.  The  calibre  of  the  intestine  was  contracted,  and  there  was 
thickening  of  the  mucous  and  muscular  coats  of  the  descending  colon.  The 
omentum  was  adherent  to  the  large  intestine  at  that  part,  where  a  large  fecal 
abscess  had  formed,  from  the  giving  way  of  the  descending  colon  above  the 
seat  of  stricture.  The  liver  was  small  and  fatty.  The  kidneys  were  small 
and  atrophied. 


464  CANCEROUS    DISEASE. 

This  case  is  one  of  much  interest,  as  showing  an  occasional  mode 
of  fatal  termination  of  cancerous  disease  of  the  intestine;  and  that 
after  ulceration  has  taken  place  at  the  seat  of  stricture  diarrhoea  may 
come  on.  Here,  however,  the  intestine  had  also  given  way,  and  had 
led  to  peritonitis,  and  the  formation  of  fecal  abscess. 

CASE  CLXVI.  Cancerous  Disease  of  the  Rectum.  Old  Hernia — In  the 
'  Guy's  Reports'  for  1850,  Mr.  Birkett  has  recorded  a  case  of  insuperable 
constipation  arising  from  stricture  at  the  upper  third  of  the  rectum,  and  asso- 
ciated with  scrotal  hernia.  The  patient  was  forty-nine  years  of  age,  and  for 
fourteen  years  he  had  had  hernia.  The  bowels  had  been  rather  constipated. 
On  June  13th  he  could  not  reduce  the  hernia,  and  applied  at  one  of  the 
London  hospitals.  On  the  18th  he  was  admitted  into  Guy's.  There  were 
slight  symptoms  of  strangulation,  but  the  hernia  was  reduced,  and  he  felt 
greatly  relieved.  On  the  21st  he  came  to  the  hospital,  suffering  very  severe 
pain  in  the  abdomen,  with  tympanitis;  the  voice  was  weak,  and  the  counte- 
nance was  expressive  of  great  anxiety ;  the  pulse  was  small  and  frequent,  and 
the  extremities  cold.  There  was  a  swelling  in  the  left  side  of  the  scrotum, 
and  although  the  patient  did  not  complain  of  pain,  there  was  much  dragging, 
with  sense  of  tightness  across  the  abdomen  ;  it  was  decided  to  make  an  ex- 
ploratory operation.  No  intestine  was  found  in  the  sac,  and  the  internal 
ring  was  perfectly  free.  He  died  on  the  26th,  nine  days  after  the  last  alvine 
evacuation.  On  inspection,  there  was  a  general  peritonitis,  and  at  the  com- 
mencement of  the  rectum  there  was  a  vascular  growth  from  the  mucous  mem- 
brane, with  thickening  of  the  submucous  tissues,  which  had  led  to  complete 
occlusion  of  the  canal.  The  hernial  sac  was  perfectly  free. 

Great  obscurity  existed  in  this  case;  examination  per  rectum  could 
not  have  reached  the  stricture,  and  the  whole  attention  of  the  patient 
was  to  the  hernia.  The  symptoms,  however,  were  more  gradual  in 
the  onset  than  ordinary  strangulated  hernia. 

CASE  CLXVII.  Cancerous  Disease  of  the  Transverse  Colon.  Fecal  Ab- 
scess.— Mary  N — ,  aet.  40,  living  at  Whitechapel,  was  admitted  September 
19th,  1856.  Two  years  previously  she  had  been  pushed  by  her  husband 
from  the  top  of  the  stairs,  and  violently  struck  her  abdomen  across  the  ban- 
ister. She  felt  great  pain  in  her  loins  when  she  recovered  herself,  and  was 
unable  to  assume  the  erect  posture,  but  felt  more  easy  in  the  semi-upright 
position.  The  abdomen  became  distended,  and  a  large  hard  swelling  was  felt 
in  the  left  hypochondriac  and  iliac  regions.  This  tumor  gave  her  great  pain 
on  stooping,  and  she  was  unable  to  bear  any  pressure  upon  it.  She  had 
vomiting  and  diarrhoea.  The  tumor  continued  in  the  same  state  for  about  a 
year  ;  but  at  that  time  it  became  enlarged,  and  there  was  great  pain  across 
the  loins  ;  she  frequently  vomited  and  had  diarrhoea.  The  urine  occasionally 
became  scanty,  and  she  had  headache,  vertigo,  and  loss  of  appetite.  She  was 
a  woman  of  dark  complexion,  and  was  much  emaciated,  cachectic,  and 
slightly  jaundiced  ;  a  tumor  was  felt  in  the  left  iliac  and  hypochondriac  re- 
gions ;  it  was  tender  on  pressure,  and  appeared  to  be  felt  in  the  loins ; 
the  bowels  were  relaxed,  the  urine  dark  colored,  but  it  did  not  contain  any 
pus.  The  diarrhoea  continued  with  occasional  vomiting  till  death,  on  the 
18th  October. 

Inspection  was  made  on  the  20th.  The  body  was  slightly  jaundiced.  The 
thoracic  viscera  were  healthy,  but  colored  with  bile. 

On  opening  the  abdomen,  the  peritoneum  was  healthy,  except  towards  the 


CANCEROUS    DISEASE.  465 

left  side,  where  the  tumor  was  observed,  which  had  been  felt  during  life  in 
front  of  the  kidney.  There  were  adhesions  firmly  uniting  several  coils  of 
intestine  together.  On  separating  them,  which  could  be  done  without 
tearing  the  intestine,  a  feculent  cavity  was  found,  bounded  above  by  the 
transverse  colon,  where  it  joins  the  descending  colon,  and  by  the  greater 
curvature  of  the  stomach ;  behind,  by  the  pancreas  ;  below,  by  several  coils 
of  jejunum. 

The  transverse  colon  presented  an  irregular  opening  about  three  inches  in 
circumference,  the  edges  of  the  opening  were  thickened,  stained  by  adherent 
feces,  infiltrated  with  cancerous  product,  and  in  some  parts  were  half  an  inch 
in  thickness.  The  pancreas  at  its  lesser  extremity,  and  some  of  the  adjoin- 
ing glands,  were  infiltrated  with  cancer ;  the  stomach,  though  adherent,  was 
not  affected.  At  the  lower  part  of  the  abscess  two  coils  of  the  jejunum  were 
firmly  adherent,  and  were  perforated  ;  one,  by  a  transverse  opening  extend- 
ing about  half  across  the  intestine,  the  edges  of  which  were  everted  and  much 
ejected ;  the  other,  by  a  smaller  opening.  The  mucous  membrane  of  the 
jejunum  generally  was  injected,  and  covered  with  mucus.  The  stomach  and 
remaining  parts  of  the  intestine  were  healthy,  so  also  were  the  liver  and  kid- 
neys. The  uterus,  ovaries,  and  glands  were  healthy. 

The  disease  was  here  of  a  strictly  local  character.  The  examina- 
tion of  the  growth  showed  that  it  consisted  of  nuclei  resembling  those 
found  in  cancerous  disease,  and  the  general  appearance  was  very 
strikingly  that  of  cancer ;  still  no  other  part  was  affected.  The  blow 
which  she  had  received  at  this  part  set  up  inflammatory  disease,  and 
it  is  probable  that  a  cancerous  action  subsequently  ensued;  ulcera- 
tion  then  took  place,  and  a  fecal  abscess  formed. 

The  diagnosis  was  difficult ;  the  position  of  the  tumor  was  that 
usually  found  in  disease  of  the  glands  about  the  kidney,  but  no  ab- 
normal condition  of  the  urine  existed.  The  vomiting  was  less  per- 
sistent, and  the  diarrhoea  more  severe  than  is  usually  observed  in 
cancerous  disease  of  the  stomach ;  but  although  the  colon  was  thus 
extensively  diseased,  constipation  did  not  occur. 

CASE  CLXVIII.  Carcinoma  of  the  Rectum,  of  the  Ovaries,  and  of  the 
Peritoneum.  Acute  Peritonitis.  Scirrhus — Ann  S — ,  aet.  26,  admitted 
March  26th,  was  a  married  woman,  living  at  Dockhead,  and  her  youngest 
child  was  two  and  a  half  years  old.  For  one  year  she  had  had  difficulty  in 
the  passage  of  the  alvine  discharges.  She  was  exceedingly  ill  on  admission, 
and  no  connected  history  could  be  obtained ;  the  lowest  part  of  the  rectum 
was  sacculated,  and  about  two  inches  upwards  a  stricture  was  found,  through 
which  a  catheter  could  be  passed.  She  suffered  considerable  pain,  but  no 
vomiting;  she  gradually  sank,  and  died  April  13th. 

Inspection  seventeen  hours  after  death. — The  body  was  very  much  emaci- 
ated. At  the  apices  of  the  lungs  there  was  slight  pneumonic  consolidation, 
with  a  little  chalky  deposit.  The  heart  was  small,  and  without  fat. 

Abdomen. — The  intestines  were  distended.  The  peritoneum  was  intensely 
injected,  and  the  coils  of  the  small  intestine  were  matted  together.  The 
mesentery  was  shortened.  The  great  omentum  was  contracted  into  a  firm 
mass,  and  was  nodulated ;  nearly  the  whole  of  the  peritoneum  was  minutely 
studded  with  small  white  tubercles ;  these  were  very  numerous  upon  the 
peritoneal  surface  of  the  stomach.  The  sigmoid  flexure  and  the  upper  part 
of  the  rectum  were  very  much  distended. 
30 


466  CANCEROUS    DISEASE. 

On  taking  out  the  large  intestine,  a  growth  was  found  about  three  inches 
from  the  anus,  having  a  semi-cartilaginous  hardness.  On  its  inferior  surface 
the  infiltrated  mucous  membrane  had  a  double  lip-like  appearance,  and  was 
considerably  raised.  In  the  centre  of  the  growth,  all  the  coats  of  the  intes- 
tine were  destroyed,  and  were  infiltrated  with  heterologous  deposit.  The 
mucous  membrane  had  a  yellowish-white  appearance  on  section  ;  beneath  it 
was  a  firm,  white  fibrous  product,  mixed  with  iron-gray  pigment ;  still  lower, 
fat  with  firm  tissue.  The  whole  of  the  external  cellular  membrane  was  semi- 
cartilaginous.  On  microscopical  examination,  the  mucous  membrane  was 
found  to  consist  of  a  delicate  cellular  tissue  of  nucleated  fibres,  interlacing 
and  leaving  spaces  filled  by  elongated  and  reniform  nuclei  ;  a  few  cells  were 
observed,  but  their  cell  walls  were  very  imperfect ;  the  submucous  tissue  was 
very  beautifully  composed  of  a  series  of  bands  of  fibre  tissue,  with  intervening 
columns  of  nuclei;  at  the  upper  part  these  bands  of  fibres  formed  series  of 
arches.  The  muscular  coat  of  the  intestine  above  the  stricture  was  much 
hypertrophied.  In  the  sigmoid  flexure  above  the  stricture  were  one  or  two 
superficial  ulcers  or  abrasions.  The  descending  colon  was  filled  with  solid 
bilious  feces,  but  was  otherwise  healthy.  The  csecum  and  small  intestine 
were  also  healthy  as  to  their  mucous  membrane.  The  whole  of  the  cellular 
tissue  about  the  ovaries  was  thickened,  white,  and  infiltrated ;  both  ovaries 
also  were  infiltrated  with  cancer,  and  one  mass  was  of  a  yellowish  color,  as  if 
degenerating.  The  uterus,  vagina,  and  bladder,  were  healthy.  The  liver 
was  fatty.  The  stomach  and  spleen  were  healthy.  There  was  no  infiltration 
of  the  lumbar  nor  of  the  mesenteric  glands.  The  kidneys  and  supra-renal 
capsules  were  healthy. 

The  disease  in  this  case  began  apparently  in  the  rectum,  and  ex- 
tended from  it,  by  continuity  of  structure.  It  was  of  a  scirrbous 
character  rather  than  epithelial,  and  although  the  obstruction  was  so 
great  as  only  to  allow  a  goose-quill  to  pass,  no  vomiting  was  pro- 
duced by  the  constipation;  the  reverse  would  have  been  the  case  if 
violent  drastics  had  been  administered.  The  character  of  the  pain 
in  this  instance  was  more  severe  than  we  find  in  disease  of  the  sig- 
moid flexure ;  there  was  direct  pressure  on  the  nerves  of  sensation, 
and  the  disease  extended  to  the  adjoining  structures.  The  growth 
could  be  felt  on  rectal  examination,  so  that  there  was  no  difficulty  in 
the  diagnosis. 

CASE  CLXIX.  Epithelioma  of  Rectum.  Contraction  and  Obstruction. 
Artificial  Anus  in  the  Loins.  Diseased  Appendix  Cceci.  Fecal  Abscess. — 
Mary  P — ,  get.  48,  was  admitted  into  Guy's  Hospital,  October  7th,  1859. 
She  had  suffered  from  constipation  for  three  weeks,  accompanied  with  vomit- 
ing, and  great  abdominal  distension.  She  was  a  thin  person,  having  an 
aged,  haggard  expression  ;  and  when  brought  to  Guy's  she  was  in  such  a 
condition  that  life  was  despaired  of  for  many  hours.  The  abdomen  was  much 
distended,  but  free  from  pain,  and  there  were  resonance  and  distension  in  the 
loins.  On  October  8th,  Mr.  Bryant  made  an  incision  into  the  left  loin,  and 
opened  the  descending  colon  ;  thin  feces  were  abundantly  discharged ;  the 
operation  was  performed  without  unusual  difficulty,  but  the  patient  gradually 
sank,  and  died  on  October  19th,  at  midnight. 

The  inspection  was  made  fifteen  hours  after  death.  The  body  was  very 
thin,  and  the  abdomen  collapsed  ;  the  peritoneum  in  some  parts  had  lost  its 
shining  surface,  but  there  was  no  evidence  of  general  peritonitis.  The  peri- 
toneum covering  the  iliac  fascia  on  the  left  side  was  thin  and  green,  and 


CANCEROUS    DISEASE.  467 

nearly  perforated.  The  rectum  passed  directly  up  to  the  caecum,  then  turned 
to  the  left  along  the  brim  of  the  pelvis ;  at  the  angle  was  a  small  fecal  abscess, 
bounded  by  the  rectum,  caecum,  and  by  a  portion  of  small  intestine  ;  it  con- 
tained the  appendix,  which  was  obliquely  truncated  near  the  ceecum  by  ulcer- 
ation;  there  was  a  contracted  portion  of  rectum  about  the  centre  of  the 
concavity  of  the  sacrum,  having  the  appearance  externally  as  if  girt  with  a 
portion  of  string.  On  opening  the  bowel  it  was  found  to  be  nearly  occluded; 
it  was  ulcerated  on  its  inferior  aspect;  and  above,  it  had  a  raised,  slightly 
vascular  fringe;  there  was  no  enlargement  of  glands.  The  opening  into  the 
descending  colon  was  well  situated ;  it  was  about  one  inch  in  length ;  the 
mucous  membrane  had  united  to  the  muscle  immediately  beneath ;  but 
beyond  that,  near  the  skin,  the  tissues  were  in  a  state  of  slough,  and  feces 
had  burrowed  down  under  the  fascia,  so  as  to  occupy  the  whole  of  the  iliac 
fossa;  this  fecal  abscess  nearly  perforated  the  peritoneum,  and  extended  into 
the  labinm  on  the  left  side,  where  was  a  small  opening.  The  bladder  was 
distended.  The  liver  was  pressed  down ;  a  white  thickened  patch  existed  on 
its  surface. 

This  patient  was  too  prostrate  to  allow  of  reparative  changes 
after  the  operation  had  been  performed,  so  that  fecal  extravasation 
took  place  in  the  loin;  the  disease  in  the  rectum  was  of  a  local  kind, 
and  the  operation  was  skilfully  performed;  still,  not  only  was  sur- 
gical help  deferred  too  long,  for  when  first  admitted  she  was  almost 
dying,  but  the  fecal  abscess  arising  from  a  perforated  appendix  caeci, 
would  in  itself  have  led  to  a  fatal  termination. 

CASE  CLXX.  Cancer  of  the  Jejunum,  and  of  the  Mesenteric  Glands. 
Softening  of  the  Spinal  Cord.  Paraplegia — Samuel  S — ,  aet.  15,  was  ad- 
mitted into  Guy's  Hospital  under  Dr.  Rees's  care,  December  17th,  and  died 
on  the  31st.  After  a  fatiguing  march,  in  a  rifle  corps,  five  weeks  previous 
to  the  commencement  of  his  illness,  he  began  to  suffer  from  "pins  and 
needles"  in  his  legs,  followed  by  weakness  and  complete  paraplegia.  The 
respiratory  muscles  became  involved  before  death.  A  tumor  was  felt  in  the 
lower  part  of  the  abdomen,  near  the  anterior  and  superior  spinous  process  of 
the  ilium  on  the  right  side;  but  neither  history  of  abdominal  pain  nor  any 
distressing  abdominal  symptom  was  made  out  during  life.  The  bowels  acted 
without  purgative  medicine;  the  motions,  however,  were  discharged  involun- 
tarily. 

On  inspection,  the  spinal  membranes  were  found  to  be  clear,  but  rather 
more  adherent  than  usual ;  the  vessels  also  appeared  very  full  of  blood ;  and 
at  the  upper  part  of  the  dorsal  region  the  cord  had  a  diffused  ecchymosed 
appearance,  several  points  of  extravasated  blood  were  also  found.  In  the 
lumbar  and  lo\ver  part  of  the  dorsal  region  the  cord  was  hard,  but  at  the 
upper  part  it  became  soft,  and  in  some  parts  semi-diffluent;  one  or  two  spots 
were  more  prominent  than  others  in  this  softened  portion. 

Abdomen The  peritoneum  was  healthy ;  the  omentum  was  spread  down 

to  the  pelvis,  and  was  adherent  near  the  right  iliac  region  to  a  hard  mass, 
about  three  inches  in  circumference,  consisting  of  an  erLirged  and  infiltrated 
mesenteric  gland ;  a  distended  coil  of  jejunum  was  adherent  at  the  part  to 
the  omentum.  The  caecum  was  free  and  empty,  and  was  situated  behind 
and  a  little  to  the  right  of  the  growth  just  mentioned.  On  removing  the 
intestine  and  opening  the  distended  portion  opposite  to  its  mesenteric  attach- 
ment, it  was  found  to  consist  of  about  six  inches  of  jejunum  dilated  into  a 
large  sac ;  at  the  entrance  into  this  sac  the  mucous  membrane  was  infiltrated 
with  cancerous  product,  so  that  the  valvulae  conniventes  were  hard  and 


468  CANCEROUS    DISEASE. 

prominent ;  a  similar  state  also  existed  at  the  outlet  of  this  sac ;  in  some 
portions  of  this  distended  bowel  the  coats  were  very  much  thinned,  as  if 
about  to  perforate  into  the  peritoneum.  The  mucous  membrane  of  the  jeju- 
num, however,  was  entire.  A  mesenteric  gland  in  the  centre  of  this  coil  of 
jejunum  was  infiltrated  with  medullary  cancer;  it  was  very  soft  and  pale  in 
color;  other  glands  were  infiltrated  in  a  less  degree;  and  one  or  two  near 
the  pancreas  were  also  enlarged.  The  growth  in  the  jejunum  consisted  of 
yellow  cancerous  matter  infiltrating  the  coats  of  the  intestine.  In  another 
portion  of  the  jejunum  there  was  a  white,  hard  mass,  opposite  to  the  mesen- 
teric attachment,  about  one  inch  in  length,  and  one-eighth  of  an  inch  in 
thickness,  consisting  of  cancerous  infiltration  into  the  submucous  cellular 
tissue,  but  the  mucous  membrane  was  entire.  The  colon,  stomach,  duodenum, 
and  pylorus  were  healthy.  The  liver  and  spleen  were  fissured,  but  free  from 
disease;  there  were  several  cancerous  masses  in  the  kidney,  and  the  epididy- 
mis  was  enlarged.  The  lumbar  tubercles  in  glands  were  normal.  The  left 
lung  was  solidified  at  its  base. 

The  spinal  mischief  led  to  a  fatal  termination,  but  the  case  is 
remarkable  not  only  in  the  form  and  situation  of  the  cancerous 
disease,  but  in  the  comparative  absence  of  symptoms  of  abdominal 
mischief.  No  obstruction  took  place  in  the  intestinal  tract,  and  the 
peritoneum  was  not  involved.  If,  however,  life  had  been  prolonged 
for  a  short  time,  the  more  extensive  affection  of  the  mesenteric 
glands  and  the  implication  of  the  peritoneum  would  soon  have  led 
to  well-marked  indications  of  abdominal  disease. 

CASE  CLXXI.  Cancerous  Ulcer  of  the  Colon  opening  into  the  Duode- 
num. Diarrhoea.  Vomiting — Ann  S— ,  aet.  47,  a  greengrocer,  who  had 
worked  hard,  and  drank  freely  ;  her  father  died  from  phthisis,  but  with  the 
exception  of  an  attack  of  acute  rheumatism,  and  of  erysipelas  ten  years  be- 
fore her  last  illness,  she  had  enjoyed  good  health.  Five  and  a  half  years 
before  admission  she  had  free  access  to  a  fruit  garden,  and  partook  of  fruit 
to  excess  ;  severe  diarrhoea  and  depression  followed.  Eighteen  months  after- 
wards the  skin  became  slightly  jaundiced,  and  her  medical  attendant  found  a 
tumor  about  the  size  of  a  hen's  egg  immediately  above  the  superior  spinous 
process  of  the  left  ilium.  She  had  also  suffered  from  haemorrhoids,  and 
from  tapeworm.  When  she  applied  for  admission  at  Guy's  Hospital,  Novem- 
ber 15th,  1859,  she  was  pale  and  had  a  careworn  appearance;  there  was 
brown  discoloration  of  the  abdomen,  neck,  thighs,  and  elbows,  the  gums 
were  pale,  and  the  tongue  was  clean.  The  resonance  of  the  chest  was  good, 
and  the  respiration  was  healthy.  The  pulse  was  90,  and  compressible.  The 
abdomen  was  supple  and  resonant,  excepting  in  the  region  of  the  caecum, 
where  a  rounded,  uneven  and  hard  tumor  could  be  felt,  about  the  size  of  a 
turkey's  egg.  There  was  slight  dulness  at  that  part,  but  no  pain  except 
when  pressure  was  made,  or  when  a  deep  inspiration  was  taken,  or  after 
swallowing  fluids  ;  pain  extended  also  in  the  course  of  the  ilio-hypogastric 
nerve,  reaching  as  far  as  the  trochanter,  and  also  back  to  the  spine  ;  on  pres- 
sure, also,  the  pain  was  produced  in  the  inguinal  region  of  the  opposite  side. 
The  bowels  were  relaxed,  and  mucus  was  passed  in  the  motions  ;  the  urine 
was  of  light  color,  of  sp.  gr.  1015,  and  free  from  albumen  and  sugar.  There 
was  good  appetite ;  nausea  was  present,  but  no  vomiting.  Eight  leeches 
were  applied,  and  a  poultice  ;  the  spermaceti  mixture  given,  and  Dover's 
powder  with  gray  powder  every  night.  The  pain  was  relieved  by  the  leeches, 
but  on  the  24th  it  again  became  very  severe,  and  the  bowels  were  relaxed. 


CANCEROUS    DISEASE.  469 

The  leeches  were  repeated,  and  calomel  and  opium,  of  each  gr.  j,  given  every 
night.  25th — The  pain  was  less,  but  there  was  tenesmus  and  diarrhoea  ;  an 
enema  of  starch  with  tincture  of  opium  was  administered.  On  the  30th, 
leeches  were  repeated  to  relieve  the  pain,  and  opium  was  given. 

On  December  4th,  there  was  diarrhoea,  and  the  swelling  had  increased, 
extending  upwards  ;  vomiting  came  on.  Logwood  mixture  (G.  P.)  was 
given.  On  the  7th,  sickness  was  relieved  by  brandy  and  soda-water.  The 
symptoms  partially  subsided,  and  she  left  the  hospital  on  January  31st. 

She  was  readmitted  on  March  loth,  1860.  Fifteen  days  before,  at  3  P. 
M.,  she  had  an  inclination  to  go  to  stool,  but  before  she  could  reach  the  closet 
she  felt  something  give  way  in  the  abdomen,  and  a  profuse  discharge  of  very 
fetid  pus  took  place  from  the  bowels.  The  tumor  diminished  in  size ;  the 
bowels  continued  relaxed,  and  for  one  week  there  was  blood  in  the  evacua- 
tions ;  she  seemed  low  and  weak ;  there  was  no  appetite,  but  considerable 
thirst ;  there  was  pain  in  the  tumor  before  and  after  the  discharge,  emacia- 
tion was  manifest,  the  mouth  became  sore  and  aphthous,  and  the  urine  con- 
tained lithic  acid.  When  admitted,  she  was  emaciated,  and  her  countenance 
was  anxious  and  distressed  ;  there  was  a  deep  flush  on  the  cheeks  ;  the  eyes 
were  sunken  and  hollow,  the  tongue  was  morbidly  red,  glazed  and  cracked, 
and  there  was  aphthous  ulceration  at  the  tip ;  the  skin  was  hot  and  dry. 
The  abdomen  was  soft.  There  was  undue  prominence  over  the  right  ilium  ; 
and  pain  with  tenderness  was  present  at  the  epigastrium,  as  well  as  in  the 
right  hypochondriac  and  iliac  regions  ;  the  tumor  which  had  been  felt  so  long 
was  resonant  on  percussion.  The  hepatic  dulness  extended  two  inches  below 
the  sternum  ;  the  appetite  was  bad,  and  she  complained  of  thirst  and  nausea ; 
the  bowels  were  moved  ten  to  twelve  times,  and  the  motions  consisted  of  very 
fetid  brown  fluid,  containing  scarcely  any  solid  matter,  and  no  blood.  The 
urine  was  scanty.  The  compound  decoction  of  krameria  was  given  every 
six  hours,  with  brandy,  milk,  arrowroot,  &c. 

March  25th — For  two  days  obstinate  vomiting  tried  the  patient ;  it  in- 
creased in  severity,  and  came  on  after  any  exertion,  and  after  taking  food  ; 
rapid  prostration  followed,  and  death. 

On  inspection,  the  thoracic  viscera  were  found  to  be  healthy.  In  the  ab- 
domen, the  ascending  colon  was  firmly  fixed  in  the  right  loin,  and  it  was 
adherent  to  the  surface  of  the  liver  ;  but  the  liver  and  kidneys  could  be  re- 
moved without  interfering  with  the  diseased  part.  On  opening  the  colon 
there  was  found  in  the  ascending  part,  just  above  the  caecum,  a  large  carcino- 
matous  ulcer,  as  large  as  the  palm  of  the  hand ;  it  was  circumscribed  and 
surrounded  by  raised  edges  of  morbid  structure.  In  some  parts  of  the  dis- 
eased tissue  the  edges  were  undermined,  so  that  bridles  of  tissue  passed 
across.  At  the  bottom  of  the  ulcer  was  a  large  hole,  through  which  the 
middle  finger  could  easily  be  passed,  and  entered  at  once  into  the  duodenum. 
On  opening  the  duodenum  the  perforation  was  seen  within  it ;  the  hole  was 
as  large  as  that  in  the  colon,  but  its  edges  were  merely  fringed  by  the  new 
growth.  The  duodenal  opening  was  near  the  pylorus,  and  opposite  to  the 
common  bile  duct,  so  that  the  bile  might  have  at  once  passed  into  the  colon. 
The  contents  of  the  intestine,  both  small  and  large,  were  of  a  pale  slate 
color,  showing  the  absence  of  bile.  The  liver  was  very  fatty,  and  it  was 
lighter  than  water.  The  kidneys  were  healthy.  The  omentum  was  adherent 
to  the  right  ovary,  and  the  Fallopian  tube  was  adherent  to  the  ovary. 

In  this  case  there  was  evidence  of  chronic  disease  of  the  caecum 
or  of  the  colon,  as  shown  by  the  gradually  increasing  tumor;  the 
pain  increasing  at  once  on  drinking  fluids  was  very  manifest.  The 


470  •    CANCEROUS    DISEASE. 

enteric  irritation  was  propagated  to  other  parts  of  the  intestine,  and 
diarrhoea  was  produced;  this  in  connection  with  pain  was,  for  a  long 
time,  a  very  troublesome  symptom.  About  a  month  before  her 
death,  at  the  time  that  something  was  felt  to  have  given  way  in  the 
abdomen,  the  opening  into  the  duodenum  was  probably  suddenly 
made,  and  from  that  time  vomiting  was  a  more  constant  symptom; 
there  was  no  evidence,  however,  by  stercoraceous  vomiting,  that 
fecal  matter  passed  from  the  colon  into  the  duodenum.  As  to  the 
cause  of  the  disease  of  the  colon,  it  is  possible  that  the  primary 
irritation  of  the  intestine  after  partaking  of  a  large  quantity  of  fruit, 
might  have  determined  the  seat  of  the  disease;  this,  however,  is 
very  doubtful.  From  the  first,  the  treatment  was  in  a  great  meas- 
ure palliative  rather  than  strictly  remedial;  but  much  may  be  done 
in  these  cases  to  diminish  the  sufferings  of  the  patient  and  to  prevent 
the  rapid  extension  of  the  disease. 

CASE  CLXXII.  Ulceration  of  the  Colon.  Intestinal  Obstruction  from 
Contraction  of  the  Transverse  Colon.  Cancer  ?  Dysentery.  Constipation. 
Diarrhoea.  (For  the  following  case  I  am  indebted  to  my  friend  Dr.  Wilks). 
— David  B — ,  set.  72,  was  a  rather  spare  man,  of  middle  stature,  and  with 
a  yellowish  complexion,  but  he  had  never  been  abroad  ;  his  habits  had  been 
rather  intemperate  He  stated  that  his  general  health  had  been  tolerably 
good,  until  within  the  last  few  years,  during  which  he  had  suffered  at  fre- 
quent intervals  from  diarrhoea,  with  colic  in  the  abdomen,  and  often  from 
painful  defecation.  His  bowels  were  at  times  so  irritable  that,  after  .swallow- 
ing only  a  cup  of  tea  they  acted  immediately  and  almost  before  he  could  reach 
the  closet-;  these  symptoms  became  increasingly  severe.  Nine  years  pre- 
viously, also,  he  had  received  a  blow  in  the  left  groin,  which  produced  u 
femoral  hernia ;  it  was  reducible,  and,  with  a  truss,  did  not  give  him  much 
inconvenience. 

On  August  llth,  1855,  he  complained  of  diarrhoea,  stating  that  his  bowels 
were  relaxed  several  times  during  the  day,  and  that  he  suffered  at  times  from 
severe  pain  in  the  abdomen  ;  the  pulse  was  full,  75  ;  the  tongue  was  clean  ; 
the  appetite  was  good  ;  and,  excepting  the  symptoms  just  mentioned,  he 
seemed  to  be  in  good  health.  He  was  ordered  chalk  mixture  with  aromatic 
confectian  three  times  a  day. 

On  the  14th,  the  bowels  were  less  relaxed,  but  the  pain  in  the  abdomen 
was  augmented  ;  and  sulphuric  ether,  with  tincture  of  opium,  was  given  in 
pimento  water  every  four  hours. 

On  the  16th,  the  abdominal  pain  had  greatly  increased,  it  was  nearly  con- 
stant, but  at  intervals  became  more  severe ;  there  was  no  tenderness  on  pres- 
sure at  any  particular  part,  but  the  greatest  amount  of  pain  was  felt  about 
the  umbilical  region  ;  the  bowels  had  not  been  open  for  two  days.  The  con- 
stipation was  relieved  by  purgatives,  but  there  was  return  of  severe  colic,  and 
vomiting  and  tympanitis  came  on.  He  gradually  became  prostrate,  and  diar- 
rhoea supervened  before  death  on  the  29th. 

Inspection.  August  30th — The  body  was  spare,  but  not  much  wasted. 
The  abdomen  only  was  examined.  There  was  no  recent  acute  peritonitis. 
The  intestines  were  distended,  injected  and  covered  with  a  slight  exudation 
of  lymph.  The  seat  of  stricture  was  at  once  seen  to  be  the  middle  portion 
of  the  transverse  colon,  exactly  in  the  median  line  of  the  body;  the  omen- 
turn  was  found  abnormally  adherent  to  this  portion  of  the  intestine,  and  a 
dark-colored,  hard-looking  substance  was  recognized ;  this  formed  the  con- 


CANCEROUS    DISEASE.  471 

stricted  portion  of  the  intestine,  and  both  above  and  below  it  there  was  con- 
siderable dilatation.  On  removing  this  portion  of  the  intestine,  the  disease 
was  felt  as  a  hard  tumor  situate  in  the  substance  of  the  organ,  and  producing 
the  constriction.  Although  the  exterior  continuity  of  the  bowel  exhibited  a 
considerable  falling  in  at  this  part,  its  lessened  calibre  was  not  so  manifest 
from  the  exterior  as  from  the  interior.  When  the  intestine  was  opened,  its 
channel  was  found  to  be  so  reduced  in  size  that  it  would  only  admit  a  goose  quill. 
On  laying  the  whole  of  it  open,  the  diminished  passage  was  found  to  be  owing, 
not  only  to  the  external  peritoneal  puckering,  but  to  the  hypertrophy  of  the 
subserous  cellular  tissue,  and  of  the  muscular  coat,  and  to  a  raised  spongy 
condition  of  the  mucous  membrane.  When  spread  out,  the  diseased  surface 
occupied  a  space  not  much  larger  than  that  of  a  five-shilling  piece.  The 
mucous  membrane  was  red,  highly  vascular,  and  completely  separated  from 
the  healthy  surrounding  structures,  not  only  by  its  color,  but  by  its  highly 
raised  margin,  which  was  considerably  above  the  level  of  the  adjacent  mucous 
membrane.  It  had  a  soft,  spongy  appearance,  and  the  muscular  coat  beneath 
was  much  hypertrophied.  The  microscope  showed  the  surface  of  the  struc- 
ture to  be  composed  of  highly  vascular  branching  villi.  The  surface  was 
covered  over  with  an  abundance  of  columnar  epithelium.  More  deeply  seated 
was  found  a  delicate  fibre  tissue,  with  a  number  of  small  nucleated  cells,  of  a 
shape  resembling  ordinary  or  abortive  epithelium.  The  caecum  and  ascend- 
ing colon,  as  well  as  the  lower  part  of  the  descending  colon  and  the  rectum, 
contained  numerous  ulcers  in  various  stages  of  healing ;  most  of  them  were 
quite  healed,  and  presented  only  cicatrices.  There  were  large  irregular  shaped 
portions  of  mucous  membrane,  of  a  dark  blue  or  slate  color,  which  seemed  to 
have  been  ulcerated,  and  caused  a  considerable  puckering  of  the  surface. 
In  the  caecum  and  rectum  the  general  calibre  of  the  intestine  was  much 
altered  in  shape  by  the  contraction,  and  also  by  the  hypertrophy  of  the  mus- 
cular coat,  which  was  very  considerable  in  the  caecum.  The  liver  contained 
no  cancerous  disease,  nor  did  any  of  the  abdominal  glands. 

Simple  acute  disease  of  a  dysenteric  character  took  place  in  this 
patient,  ulceration  followed,  and,  at  the  seat  of  one  of  these  ulcers, 
a  villous  growth  was  developed,  which  led  subsequently  to  con- 
striction ;  the  coats  of  the  intestine  at  that  part  were  hypertrophied, 
showing  that  the  obstruction  had  existed  for  some  time.  As  to  the 
nature  of  the  growth,  although  no  strictly  cancerous  product  was 
found,  and  although  no  glandular  disease  was  present,  its  villous 
character  and  cellular  substratum  showed  that  it  belonged  to  the 
class  of  growths  designated  as  cancerous.  The  first  symptoms  were 
those  of  dysentery,  as  shown  by  the  diarrhcea  and  the  discharge  of 
mucus;  but  as  the  disease  extended  to  the  deeper  structures,  and 
spasmodic  contraction  took  place  at  the  seat  of  the  villous  growth, 
the  obstruction  became  complete,  till  vomiting  even  of  a  stercora- 
ceous  kind  was  set  up;  and  it  was  only  as  the  strength  of  the  patient 
failed  that  the  constriction  yielded  and  the  bowels  acted;  diarrhcea 
then  came  on,  and  continued  till  death.  In  the  treatment  of  the 
patient,  the  increase  of  the  symptoms  after  purgative  medicines,  and 
their  relief  after  the  administration  of  opium,  were  well  marked. 

These  instances  show,  that  with  care  the  several  forms  of  internal 
strangulation  may  be  generally  distinguished,  when  we  have  the 
whole  of  the  symptoms  before  us ;  that  whilst  over-active  and  inju- 


472  CANCEROUS    DISEASE. 

dicious  treatment  increases  discomfort  and  hastens  a  fatal  termina- 
tion, much  may  be  done  for  the  relief  of  the  patient,  and  valuable 
lives  may  thereby  be  prolonged.  These  are  not  the  cases  for  do- 
nothing  practice  ;  the  proper  use  of  enemata,  of  such  diet  only  as  can 
be  borne  without  injury,  opium,  rest,  and  other  means  to  which  we 
have  referred,  will  mitigate  suffering  even  where  cure  is  impossible. 


473 


CHAPTER    XVII. 

SUPPURATION  IN  THE  ABDOMINAL  PARIETES.  PERFORATION  OF  THE  IN- 
TESTINE FROM  WITHOUT.  ABSCESS  IN  THE  ABDOMINAL  PARIETES  EX- 
TENDING INTO  THE  INTESTINE.  FECAL  ABSCESS. 

PERFORATION  of  the  coats  of  the  small  intestine  ranks  in  the  order 
of  frequency  next  to  perforation  of  the  stomach ;  the  colon  is,  how- 
ever, perforated  more  frequently  than  is  generally  supposed.  These 
perforations  of  the  intestinal  tract  divide  themselves  into  two  great 
classes  :  1st.  Those  which  arise  from  disease  commencing  in  the  in- 
testine itself,  and  to  which  we  have  referred  in  numerous  instances, 
as  perforation  of  the  ileum  in  typhoid  fever  and  in  phthisis;  of  the 
caecum  and  its  appendix  ;  of  the  colon  in  dysentery,  in  cancerous  dis- 
ease, and  in  several  forms  of  insuperable  constipation.  2d.  Those 
in  which  the  perforation  is  from  without,  or  from  the  extension  of 
disease  from  adjoining  structures.  These  latter  cases  constitute  an 
important  and  an  exceedingly  interesting  class  of  diseases ;  and  the 
following  causes  of  external- perforation  may  be  enumerated: — 

1.  From  the  peritoneum,  as  in  strumous  peritonitis  and  localized 
peritoneal  abscess. 

2.  From  disease  of  the  stomach,  as  ulceration  and  cancer,  extend- 
ing into  the  transverse  colon. 

3.  From  hydatids  and  abscess  of  the  liver,  thus  forming  a  means 
of  escape  into  the  small  or  large  intestine. 

4.  From  calculi  in  the  gall-bladder,  setting  up  ulceration  of  the 
duodenum  or  of  the  colon. 

5.  From  abscess  in  the  spleen. 

6.  From  abscess  in  the  kidney. 

7.  From  abscess  in  the  abdominal  parietes  and  loins  opening  into 
the  intestine. 

8.  From  diseased  ovary  communicating  with  the  caecum,  colon,  or 
rectum. 

9.  From  cancer  of  any  of  the  abdominal  organs  extending  into  the 
intestine. 

10.  From  extra-uterine  foetation. 

11.  From  one  portion  of  intestine  opening  into  another,  as  the  ap- 
pendix into  the  rectum. 

12.  From  blows,  and  external  injury. 

In  many  of  these  forms  of  disease  last  enumerated,  various  and 
characteristic  symptoms  precede  the  perforation  of  the  peritoneum 
and  of  the  intestine ;  thus,  the  signs  of  cancerous  disease  of  the  sto- 
mach arise  some  time  before  fecal  eructation  or  vomiting  indicate 
extension  into  the  colon.  In  hydatid  disease  of  the  liver  a  rounded 
tumor,  of  slow  formation,  is  detected,  having  often  a  peculiar  vibra- 


474         PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT. 

tory  thrill,  and  without  general  disturbance,  before  the  occurrence 
of  local  peritonitis  takes  place,  and  the  hydatids  are  discharged  either 
by  the  mouth  or  with  the  evacuations  per  rectum. 

In  gall-stone  very  severe  pain  arises  in  the  region  of  the  gall-blad- 
der with  vomiting  and  often  with  jaundice,  before  ulceration  takes 
place,  and  perforation  be  made  into  the  duodenum  or  into  the  colon. 
Peritoneal  adhesions  generally  prevent  severe  inflammation  of  the 
serous  membrane. 

In  abscess  of  the  spleen  the  symptoms  are  more  obscure,  and  con- 
stitute part  of  a  general  constitutional  disturbance,  till  perhaps  the 
discharge  of  pus  by  stool  indicates  that  a  communication  has  been 
formed  with  the  transverse  or  descending  colon. 

In  abscess  of  the  kidney,  and  pyelitis,  there  is  purulent  urine; 
but  when  there  is  suppuration  external  to  the  tunic  of  the  gland  the 
symptoms  are  more  obscure. 

In  ovarian  and  cancerous  tumors  tactile  examination  will  detect 
them.  Some  of  these  forms  of  disease  are  more  obscure  than  others, 
but  when  fecal  abscess  is  the  result  there  is  considerable  uniformity 
in  their  character ;  severe  local  pain  arid  tenderness  come  on,  with 
hectic  fever,  and  steadily  increasing  prostration;  and  when  the  ab- 
scess is  not  limited  by  adhesion,  a  rapidly  fatal  result  occurs. 

Suppuration  in  the  parietes  of  the  abdomen  is  frequently  observed, 
and  simulates  deeply-seated  mischief;  and  for  a  short  time  consider- 
able obscurity  may  attend  it.  (the  symptoms  are  generally  of  an 
acute  character;  considerable  pain  and  febrile  excitement  precede 
inflammatory  oedema  of  the  skin,  and  while  the  effused  products  are 
bound  down  by  firm  fascial  investments  the  symptoms  closely  re- 
semble caecal  disease,  and  local  peritonitis ;  in  fact  every  part  of  the 
abdominal  parietes  presents  us  with  disease  on  the  surface,  resem- 
bling deeper  injury,  and  the  structures  beneath  sympathize  with  the 
external  disease.  Thus  jaundice  may  come  on  with  abscess  in  the 
right  hypochondrium,  constipation  and  distended  bowel  may  be  found 
in  cases  of  inflammation  behind  the  ascending  or  descending  colon. 
Movement  of  the  bowel  induces  pain  and  delay  in  the  passage  of  the 
contents.  In  the  hypochondriac  regions  suppuration  connected  with 
the  costal  cartilages  and  ribs  simulates  abscess  of  the  liver,  empyema, 
hydatids,  diseased  gall-bladder,  or  corresponding  disease  of  the  spleen; 
in  the  right  and  left  iliac  regions  abscess  in  the  parietes  may  be  mis- 
taken for  affections  of  the  caecum  and  sigmoid  flexure  of  the  colon ; 
in  the  lumbar  regions,  for  renal  and  spinal  disease;  in  the  umbilical, 
for  strumous  and  cancerous  disease ;  arid,  lastly,  in  the  hypogastric 
region,  pelvic  cellulitis,  for  ovarian  and  uterine  disease. 

Simple  suppuration  in  the  parietes  generally  tends  to  the  surface, 
and  the  abscess  is  opened  or  it  is  discharged  spontaneously,  and  in 
many  cases  recovery  takes  place,  unless  the  disease  be  associated 
with  pyaemia,  or  occur  in  cachectic  subjects ;  sometimes  the  suppu- 
ration spreads  extensively  among  the  muscles ;  it  extends  also  in 
d"epth,  and  gradually  produces  local  peritonitis,  or  discharges  itself 
into  some  of  the  viscera.  Thus  abscess  about  the  kidney  opens  into 


PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT.         475 

the  colon,  that   in   the   iliac  regions  into   the  sigmoid  flexure    or 
caecum. 

The  most  fertile  sources  of  these  forms  of  parietal  suppuration  are 
blows  and  falls.  I  have  observed  them  from  blows,  from  pressure 
on  the  abdomen,  and  from  falls  on  the  back,  &c.  In  pyaemia  and  in 
cachectic  subjects  very  trifling  causes  appear  to  be  sufficient  to  lead 
to  this  disease.  A  rupture  of  the  muscular  fibre  is  followed  by  ex- 
travasation of  blood,  and  suppuration  may  supervene. 
^  Diagnosis.— The  pain  will  generally  be  found  to  be  very  super- 

sial ;  but  m  many  instances,  at  an  early  stage,  before  any  inflam- 
matory oedema  has  been  produced  on  the  skin,  and  whilst  the  disease 
is  confined  beneath  the  fascia  of  the  abdomen,  there  is  much  obscurity 
in  the  diagnosis ;  and  after  pus  is  discharged,  it  must  be  remembered 
that  a  fecal  odor  does  not  necessarily  imply  communication  with  the 
intestine;  for  transfusion  of  the  gaseous  contents  of  the  intestine, 
when  there  is  tolerably  close  contact,  may  cause  the  contents  of  an 
abscess  to  have  a  fecal  smell.  In  the  diagnosis,  it  is  important  to 
bear  in  mind  the  remark  we  have  just  made  as  to  the  sympathv  of 
adjoining  viscera.  We  refer  to  the  production  of  jaundice  in  disease 
in  the  right  hypochondrium.  Abscess  below  the  diaphragm  often 
leads  to  congestion  and  inflammation  of  the  pleura  and  lung  which 
may  be  mistaken  for  the  primary  disease. 

In  reference  to  the  treatment  this  early  obscurity  is  of  no  great 
moment,  for  at  that  period,  rest,  warm  cataplasms,  local  depletion, 
and  counter-irritation,  are  equally  applicable  to  local  peritonitis  as 
to  parietal  inflammation.  When  suppuration  has  actually  taken 
place,  the  sooner  the  pus  is  evacuated  the  less  likely  is  it  to  burrow 
among  the  flat  muscles  and  fascia  of  the  abdomen  ;  and  even  in 
abscesses,  fecal  or  otherwise,  extending  secondarily  to  the  parietes, 
unnecessary  delay  is  sometimes  made  in  discharging  their  contents. . 
The  rule  is,  I  believe,  a  correct  one,  to  open  these  abscesses  verv 
early. 

CASE  CLXXIII.  Suppuration  external  to  the  Sigmoid  Flexure  of  the 
Colon,  opening  on  the  Anterior  Abdominal  Parietes,  and  communicating 
with  the  Intettine.— Elizabeth  R— ,  *t.  39,  'a  widow,  who  had  supported 
herself  by  dressmaking,  was  admitted  into  Guy's  Hospital,  under  my  care, 
in  March,  1855.  Till  a  fortnight  before  admission  she  had  enjoyed  good 
health,  when  she  felt  pain  in  the  back,  which  extended  to  the  shoulders  and 
knees.  The  greatest  pain,  however,  was  in  the  course  of  the  ilio-hypogastric 
nerve.  These  symptoms  were  accompanied  with  considerable  febrile  excite- 
ment. In  a  few  days  the  pain,  which  had  simulated  rheumatism,  ceased, 
and  she  gained  strength. 

On  March  26th,  three  weeks  after  admission,  she  complained  of  pain  in 
the  left  iliac  fossa,  and  a  firm  tumor  about  the  size  of  a  hen's  egg  could  be 
felt  deeply  in  that  part.  There  was  no  tenderness  in  the  spine,  no"numbness 
in  the  legs,  nor  other  symptoms  of  disease  of  the  spine,  nor  was  there  any 
evidence  of  disease  of  the  ovary.  The  bowels  were  easily  acted  on,  but  this 
action  did  not  affect  the  size  of  the  tumor  nor  alleviate  the  symptoms.  The 
urine  was  normal,  and  there  was  no  indication  of  renal  disease. 

May  10 — The  pain  had  returned  with  much  severity,  and  hectic  came  on. 
The  tumor  increased  -in  size ;  it  could  be  felt  extending  to  the  quadratus 


476         PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT. 

lumborum ;  and  it  also  reached  to  the  anterior  abdominal  parieles,  which,  at 
the  left  iliac  fossa,  were  red,  oedematous  and  exceeding  tender. 

19th. — The  bowels  were  acted  upon  three  times  freely,  and  a  considerable 
quantity  of  purulent  mucus  was  discharged.  The  examination  of  this  dis- 
charge could  detect  no  cancer  cells.  The  pain  and  the  hectic  continued ; 
the  patient  became  pale  and  exhausted;  the  left  thigh  and  leg,  and  after- 
wards the  right,  became  swollen  and  tender ;  and  there  was  excessive  pain 
in  the  course  of  the  femoral  veins.  Nourishment  and  stimulants  were  ad- 
ministered as  the  patient  could  take  them.  Quinine  and  opium,  or  morphia 
were  given. 

On  June  8th,  the  inflammatory  oedema  of  the  anterior  abdominal  parietes 
had  increased.  My  colleague,  Mr.  Callaway,  made  an  incision  at  this  part ; 
and  more  than  a  pint  of  exceedingly  offensive  pus  was  evacuated.  Every 
means  was  used  to  sustain  the  patient ;  but  the  discharge  continued  abundant, 
and  it  had  a  feculent  odor ;  the  appetite  completely  failed,  and  at  length  her 
strength  gave  way.  Bed  sores  formed  on  the  sacrum  ;  and  a  few  days  before 
her  death  cough  came  on,  which  aggravated  her  distress.  She  gradually 
sank  and  died  June  24th. 

Inspection  was  made  twenty-four  hours  after  death.  The  body  was 
blanched,  and  the  lower  extremities  were  redematous  ;  the  posterior  lobes  of 
the  lungs  were  in  a  state  of  red  hepatization .  Abdomen — The  peritoneum 
was  healthy,  except  in  the  left  iliac  region,  where  the  omentum  and  several 
coils  of  intestine  were  adherent.  In  this  region  was  an  abscess,  situated  be- 
hind the  peritoneum  and  fascia,  and  containing  offensive,  feculent  pus ;  it 
extended  to  the  anterior  abdominal  parietes  in  front,  above  to  the  diaphragm 
and  kidney,  and  posteriorly  nearly  to  the  spine.  Very  careful  examination 
could  detect  no  disease  of  the  ilium,  nor  vertebrae,  nor  of  the  pelvic  cellular 
tissue.  The  abscess  communicated  with  the  sigmoid  flexure  by  three  small 
openings,  in  close  contact  the  one  with  the  other  ;  their  edges  were  not  thick- 
ened, but  valvular.  The  small  and  large  intestines  were  otherwise  healthy, 
and  the  opening  into  the  intestine  was  evidently  secondary.  The  uterus, 
ovaries,  and  kidneys  were  normal.  The  stomach  was  of  normal  size ;  its 
mucous  membrane  was  pale,  and  it  had  undergone  degeneration.  The  liver 
was  more  than  5  Ibs.  in  weight,  and  extremely  fatty.  The  lower  portions  of 
the  vena  cava,  and  of  the  common  iliac  and  external  iliac  veins,  were  filled 
with  very  firm,  white,  adherent  fibrin  ;  and  the  coats  of  the  veins  were  much 
thickened. 

The  review  of  this  case  showed  that  the  pain  in  the  course  of  the 
ilio-hypogastric  nerve  arose  from  direct  pressure  upon  that  nerve  by 
inflammatory  effusion  ;  that  the  tumor  felt  in  the  iliac  fossa  consisted 
of  this  effusion  pushing  forward  the  peritoneum  and  sigmoid  flexure; 
that  the  subsequent  symptoms  arose  from  suppuration,  and  its  ex- 
tension in  various  directions ;  inwards  into  the  colon,  leading  to  some 
extravasation  of  feces  into  the  abscess  and  of  pus  into  the  alimentary 
canal ;  forwards,  so  as  to  reach  the  anterior  parietes,  where  it  was 
opened ;  upwards,  to  the  diaphragm ;  and  inwards,  to  the  cava  and 
iliac  vessels,  which  became  involved  and  obstructed  by  fibrinous 
material.  That  it  did  not  arise  from  diseased  bone  was  proved  by 
careful  examination ;  and  it  is  probable  that  some  accidental  blow 
had  led  to  this  suppuration,  with  its  fatal  results ;  or,  that  irritation 
in  the  intestine  had  led  to  inflammation  external  to  it,  and  subse- 
quently to  suppuration. 


PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT.         477 

After  the  tumor  had  been  felt,  evidence  of  suppuration  soon  arose- 
and  the  discharge  of  purulent  mucus  showed  that  it  had  formed  a 
communication  with  the  intestine,  or  that  there  was  ulceration  of 
the  coats  of  the  intestine  itself.  Keual,  ovarian,  spinal,  or  parietal 
suppuration,  or  cancerous  disease  of  the  sigmoid  flexure,  might  give 
rise  to  many  of  these  symptoms.  The  absence  of  all  indication  of 
diseased  kidney  was  shown  in  the  condition  of  the  urine.  Disease 
of  the  spine  was  exceedingly  doubtful,  from  the  absence  of  tender- 
ness and  numbness,  and  from  the  course  of  the  suppuration.  The 
position  which  the  tumor  assumed  and  vaginal  examination  showed 
that  the  ovary  was  not  involved.  The  tumor  appeared  to  arise  from 
disease  near  to  the  sigmoid  flexure,  either  commencing  in  that,  viscus 
and  extending  outwards,  or  beginning  in  the  parietes  and  makin<r 
its  way  into  the  intestine.  It  was  in  deciding  as  to  which  of  these 
might  be  correct  that  the  principal  difficulty  consisted.  The  dis- 
charge of  purulent  mucus  from  the  intestine,  and  the  feculent  char- 
acter of  the  pus,  indicated  a  connection  between  the  abscess  and  the 
intestine.  Before  death,  I  was  led  to  believe  that  the  disease  com- 
menced  in  the  sigmoid  flexure,  and  that  the  suppuration  external  to 
the  intestine  was  secondary;  the  inspection  after  death  showed  that 
the  reverse  was  the  case.  This  instance  resembled  cases  of  suppu- 
ration external  to  the  rectum,  but  so  deeply  was  the  mischief  situ- 
ated, that  any  exploratory  incision  would  have  been  unjustifiable 
till  there  was  more  certain  evidence  of  suppuration  than  was  pre- 
sented at  the  commencement  of  the  disease. 

CASE  CLXXIV.  Abscess  in  the  Loins.  Feculent-smelling  Discharge. 

Pleuro-pneumonia  with  Feculent-smelling  Septum.  Recovery T.  H , 

aet.  34,  was  admitted  into  the  Clinical  Ward,  under  my  care,  June,  1855. 
He  was  a  man  of  steady  and  industrious  habits.  His  health  had  been  good 
till  an  attack  of  rheumatic  fever  two  years  before;  and  at  Christmas,  1854, 
six  months  before  admission,  he  had  a  very  severe  injury  whilst  at  work;  he 
fell  upon  his  head,  and  it  was  believed  that  the  skull  was  fractured.  He 
remained  for  some  time  in  the  hospital,  under  the  care  of  Mr.  Birkett,  but 
left  well,  and  continued  so  till  three  weeks  before  admission,  when,  in  the 
middle  of  the  night,  he  awoke  with  great  difficulty  of  breathing,  the  respira- 
tion being  accompanied  with  considerable  distress  and  pain.  These  symptoms 
increased  greatly  in  severity,  and  presented  the  signs  of  pleuro-pneumonia 
on  the  right  side. 

On  admission  he  was  exceedingly  ill;  his  countenance  was  pale;  his  eyes 
were  glistening;  the  lips  and  nostrils  were  contracted;  the  teeth  were  covered 
with  sordes;  the  tongue  was  brown  at  the  base  and  edges ;  and  the  skin  was 
hot  and  clammy.  In  the  chest  there  was  found  to  be  increased  roundness  of 
the  right  side  at  the  base,  with  imperfect  mobility,  increased  dulness  on  per- 
cussion, and  loss  of  tactile  vibration;  and  in  front,  below  the  nipple,  there 
was  a  pleuritic  rub.  On  the  left  side  the  respiration  was  peurile;  and  at  the 
apices  the  expiratory  murmur  was  prolonged  and  coarse.  The  position  of 
the  heart  was  normal;  its  sounds  were  healthy,  but  the  precordial  dulness 
was  somewhat  increased;  the  respiration  was  26  per  minute;  the  pulse  95, 
feeble  and  compressible;  the  urine  was  high  colored,  acid,  sp.  gr.  1025.  He 
reclined  on  his  back  towards  the  right  side,  with  his  knees  drawn  up,  and 
the  head  thrown  forward. 


478         PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT. 

The  prostration  increased  till  June  14th,  when  deep-seated  fluctuation 
below  the  ribs  on  the  right  side  could  be  detected  beneath  the  lumbar  fascia 
about  the  quadratus  lurnborum  muscle.  An  exploring  net-die  was  passed, 
and  afterwards  a  director,  and  the  wound  enlarged;  about  a  pint  of  pus, 
having  a  strong  fecal  odor,  was  discharged,  and  the  abscess  continued  to  dis- 
charge freely.  After  the  opening  of  the  abscess  the  respiration  became  more 
free,  and  he  coughed  up  a  considerable  quantity  of  frothy  mucus,  having  the 
same  odor  as  the  pus.  His  strength  was  sustained  by  nourishing  food  and 
stimulants;  by  quinine  and  opium;  diarrhoea  was  occasionally  troublesome, 
and  the  offensive  expectoration  became  exceedingly  distressing. 

On  July  2d,  he  had  so  much  improved  as  to  be  carried  out  into  the  open 
air  for  half  an  hour.  The  offensive  character  of  the  breath  and  respiration 
gradually  subsided  ;  healthy  respiration  became  audible  nearly  to  the  base  of 
the  lung,  and  he  continued  to  gain  flesh. 

In  October  he  returned  to  his  work,  and  then  appeared  a  stout  hale  man  ; 
but  a  flstulous  opening  remained  up  to  that  time,  which  occasionally  dis- 
charged freely.  The  sinus  healed  in  about  six  months,  and  he  then  appeared 
in  good  health,  May,  1857. 

In  this  case  deep-seated  suppuration  took  place  near  the  quadratus 
luraborum  muscle;  acute  pleuro-pneumonia  on  the  right  side,  and 
the  most  severe  constitutional  symptoms  followed.  The  pus,  which 
was  evacuated,  and  the  mucus  expectorated,  were  of  a  most  offensive 
and  feculent  odor;  but  microscopical  examination  of  the  pus  could 
not  detect  decided  fecal  elements.  Diarrhoea  came  on;  the  feculent 
character  of  the  discharges  slowly  subsided,  but  the  offensive  char- 
acter of  the  expectorated  matter  tried  the  patient  much.  Several 
facts  render  it  probable,  that  the  abscess  was  in  close  contact  with 
the  ascending  colon;  mere  contact  with  the  intestine  would  be  suffi- 
cient to  explain  the  fecal  odor;  and  it  may  be,  that  the  contents  of 
the  abscess  were  partially  discharged  into  the  colon. 

In  the  investigation  of  the  case,  several  modes  of  explanation 
were  suggested: — 1,  an  abscess,  the  result  of  the  blow;  2,  caries  of 
the  vertebrae  or  their  processes;  3,  abscess  of  the  liver;  4,  empyema; 
5,  suppuration  external  to  the  kidney,  from  disease  of  that  organ. 
Although  there  was  evidence  of  acute  disease  of  the  chest,  the 
abscess  was  evidently  below  the  diaphragm,  and  probably  in  con- 
tact with  it.  -The  character  of  the  pus,  and  the  absence  of  the 
elements  of  bile,  indicated  freedom  from  hepatic  disease.  It  is  pro- 
bable that  disease  of  a  vertebra  or  of  one  of  its  processes  had  been 
set  up  by  the  blow. 

The  treatment  in  both  the  cases  just  detailed  appears  sufficiently 
clear;  namely,  as  soon  as  a  tolerably  certain  evidence  of  suppuration 
is  obtained,  to  make  a  free  outlet  for  the  pus,  and  to  support  the 
patient  by  every  means  in  our  power. 

To  deter  the  opening  of  the  abscess  tends  to  increase  fecal  ex- 
travasation where  there  is  communication  with  the  colon;  and  in 
other  cases  the  pus  readily  extends  among  the  cellular  tissue  which 
connects  the  layers  of  fascia  and  muscle. 

CASE  CLXXV.  Abscess  in  the  Loins.  Pleuro-pneumonia.  Recovery. — 
A  Greek  sailor  was  admitted  into  Guy's  Hospital  under  my  care  in  1877, 


PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT.         479 

with  pain  in  the  left  loin,  between  the  ribs  and  the  crest  of  the  ilium  The 
^verity  of  the  febrile  disturbance  led  to  some  doubt  whether  the  patient  was 
suffering  from  enteric  fever  or  from  tuberculosis  ;  still  the  especial  complaint 
was  o  tenderness  in  the  lorn.  One  of  my  surgical  colleagues  kindly  exam. 
medium,  but  at  first  did  not  think  that  the  "symptoms  warranted^  ex- 
ploratory operation.  After  a  few  days,  when  the  pain  was  still  more  decided 
and  accompanied  with  tenderness,  pleuro-pneumonia  on  that  side  came  on 
Ihe  operation  was  again  delayed,  but  soon  the  symptoms  of  local  disease 
became  more  evident.  Mr.  Jacobson  opened  the  abscess,  and  the  patient 
lowly  recovered  ;  the  pneumonia  soon  subsided.  There  was  no  proof  of 
communication  between  the  abscess  and  the  lung,  but  the  close  proximity  of 
hsease  below  the  diaphragm  led  apparently  to  the  thoracic  mischief. 


»/,  Mifcarria9^     Pyamia.     Abscess  between  the  Uterus 

and  Bladder.  Abscess  m  the  Loins,  opening  into  the  Ascending  Colon,  and 
into  the  Iliac  Vein  For  the  following  case  I  am  indebted  to  my  friend 
Dr.  Hardwicke,  of  Leeds.  3 

Ann  D—  ,  at.  37,  was  admitted  into  the  Leeds  Infirmary,  December  12th 

hhe  was  a  married  woman,  the  mother  of  four  children,  the  youngest  bein- 

two  years  old;  she  had  enjoyed  tolerable  health;  but  had  suffered  severely 

a  rheumatism  four  years  previously,  and  from  scarlet  fever  in  her  child- 

hood.    She  had  not  menstruated  since  her  last  confinement. 

When  admitted,  the  uterus  was  enlarged  nearly  to  the  umbilicus.  Her 
present  illness  had  commenced  three  weeks  before  admission.  She  had  not 
been  suffering  previously  from  any  pain,  nor  from  disorder  of  the  bowels. 
.ring  the  day  of  the  attack  she  had  been  working  hard,  and  awoke  in  the 
night  with  violent  pain  in  the  lower  part  of  the  abdomen,  of  a  bearing-down 
character.  She  thought  that  relief  would  be  obtained  by  an  action  of  the 
bowels,  but  found  that  she  could  not  pass  anything,  and  that  the  sensation  of 
forcing  and  pain  continued.  On  the  following  day  she  got  up,  but  fainted 
and  had  a  severe  rigor  ;  on  the  third  day,  she  noticed  that  her  abdomen 
was  enlarged,  chiefly  on  the  right  side  ;  this  was  the  seat  of  all  the  pain,  and 
became  s6  tender  that  she  could  not  bear  the  weight  of  the  clothes  upon  the 
part.  Her  left  side  had  been  free  from  pain  throughout.  The  bowels  re- 
mained confined  for  four  or  five  days  after  the  commencement  of  her  illness, 
and  were  only  moved  by  a  second  dose  of  purgative  medicine.  The  consti- 
pation continued  till  the  time  of  admission.  Miscarriage  then  took  place. 
On  December  17th,  she  appeared  anxious,  and  had  a  slightly  yellow  tin<*e 
There  were  a  few  bronchial  rales  in  the  chest.  The  heart's  action 
was  irregular  and  intermittent,  but  unattended  with  any  bruit.  Her  abdo- 
men was  large,  the  superficial  veins  being  distended.  On  the  right  side 
above  the  ilium  there  was  an  elastic  tender  swelling,  with  apparent^  uctua- 
tion  in  it  ;  in  front  it  was  ill  defined,  but  above  was  separated  from  the  liver 
by  a  resonant  space.  There  were  no  symptoms  to  connect  it  with  the  kid- 
ney, and  it  did  not  extend  into  the,  right  groin.  The  tongue  was  furred  and 
The  bowels  were  purged  by  medicine.  The  urine  contained  no 
albumen,  but  at  times  the  coloring  matter  of  bile  was  in  abundance.  The 
pulse  was  irregular,  and  generally  intermitted  every  -fifth  beat. 

December  30th.  The  tumor  had  been  gradually  disappearing,  and  for  the 
last  two  days  could  not  be  detected  ;  there  was  also  resonance  at  the  part  ; 
she  complained  much  of  "  rheumatic"  pain  in  both  her  shoulders  and  elbows, 
but  less  of  pain  in  her  side  ;  the  bowels  had  been  regular  till  this  day,  when 
she  passed  three  or  four  large  evacuations,  consisting  chiefly  of  dark  coagulated 
blood.  This  continued  till  the  following  day,  when  she  sank. 


480         PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT. 

Inspection  was  made  seven  hours  after  death.  The  body  was  slightly 
wasted.  The  lungs  were  healtliy  in  structure  ;  on  the  right  side  there  were 
firm  adhesions  at  the  base.  The  pericardium  contained  about  Jiij  of  serum. 
The  heart  was  a  little  enlarged,  but  there  was  no  valvular  change.  There 
was  redness  with  effused  lymph  over  the  peritoneum  on  the  right  side;  and 
the  caecum  was  pushed  a  little  upward  and  glued  by  recent  adhesion  to  the 
posterior  wall  of  the  abdomen,  and  to  the  transverse  colon.  The  liver  was 
large  and  fatty  ;  the  gall-bladder  contained  two  calculi,  each  about  the  size  of 
a  marble.  The  spleen  was  rather  enlarged.  The  kidneys  were  large,  soft, 
and  of  loose  texture,  and  showed  but  little  distinction  between  the  cortical 
and  medullary  structures.  Numerous  small  cysts  were  found  in  their  sub- 
stance; and  the  capsule  separated  readily.  On  detaching  the  ascending  colon 
from  its  adhesions,  which  was  done  very  easily,  a  quantity  of  dark  clotted 
blood  escaped,  and  the  bowel  was  found  to  form  the  anterior  wall  of  a  large 
cavity,  filled  with  coagulated  blood.  It  occupied  the  position  of  a  psoas 
abscess,  and  extended  behind  the  psoas  muscle,  and  even  for  a  short  distance 
below  Poupart's  ligament.  The  blood  was  confined  by  the  fascia,  and  occu- 
pied the  whole  of  the  right  iliac  fossa.  There  was  a  small  portion  of  fibrin 
in  it,  but  no  pus  could  be  detected;  several  nerves  were  found  passing  from 
the  spinal  column  through  the  middle  of  the  cavity ;  and  the  iliac  vessels  lay 
on  the  inner  side  and  slightly  in  front  of  it.  The  artery  was  healthy  through- 
out;  the  vein  was  roughened  posteriorly,  and  formed  a  portion  of  the  boundary 
of  the  cavity  described.  At  the  termination  of  the  common  iliac  vein  on  the 
right  side  was  a  large  irregular  opening  posteriorly,  forming  a  communication 
between  the  vein  and  the  cavity  in  the  muscle.  Above  this  point  the  vessel 
was  healthy;  below,  and  throughout  the  external  and  internal  iliac  veins,  the 
coats  appeared  thickaned,  and  the  vessels  were  closed  by  firm  adherent  clot. 
Around  the  opening  on  the  inner  side  there  were  small  excrescences  of  lymph, 
almost  similar  to  those  sometimes  found  on  the  valves  of  the  heart.  The 
lumbar  portion  of  the  spine  was  removed,  and  carefully  examined,  but  no 
caries  nor  other  disease  could  be  found.  The  sacro-iliac  synchondrosis  was 
sound,  and  no  diseased  bone  could  be  detected  at  any  part.  The  small  intes- 
tine was  slightly  injected  at  one  or  two  points.  The  large  intestines  were 
healthy,  except  the  ascending  colon  ;  there  was  some  vascularity,  and  an  in- 
jected appearance  in  small  isolated  spaces.  On  its  posterior  wall  were  four 
or  five  large  ragged  openings,  varying  from  the  size  of  a  sixpence  to  a  shilling. 
There  was  a  brown  discoloration  of  the  bowel  for  some  distance  around  the 
openings,  and  their  edges  were  thin,  having  the  mucous  membrane  entire  as 
far  as  the  border  of  the  opening.  The  peritoneal  covering  was  roughened 
and  uneven,  being  generally  wanting  round  the  edges  of  the  openings,  so  as 
to  give  them  a  bevelled  appearance  on  their  outer  aspect.  The  colon  contained 
a  small  quantity  of  blood.  There  was  thickening  of  the  cellular  tissue  about  the 
uterus  on  the  right  side ;  and  a  circumscribed  abscess,  the  size  of  a  small  orange, 
was  found  between  it  and  the  bladder;  but  this  was  entirely  distinct  from  the 
cavity  in  the  psoas.  The  uterus  was  contracted  to  the  size  of  an  orange,  and 
felt  soft.  The  os  was  dark  and  discolored.  The  ovaries  were  small  and  flabby,  and 
did  not  present  any  corpus  luteum.  The  uterus  was  covered  internally  by  a  thin 
layer  of  dark  clot,  and  to  its  posterior  wall  was  firmly  attached  a  fibrous  mass 
of  the  same  color  and  appearance.  The  structure  of  the  walls  was  healthy. 

Many  of  the  earlier  symptoms  in  this  case  arose  from  threatening 
miscarriage  after  a  day  of  hard  work  ;  and  it  appeared  probable  that 
a  state  of  pyaemia  was  afterwards  produced,  and  would  have  pro- 
bably terminated  fatally,  if  the  hemorrhage  from  the  divided  cava 
had  not  led  to  comparatively  sudden  death.  The  cause  of  the  abscess 


PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT.         481 

behind  the  colon,  which  extended  into  the  cava,  and  afterwards  into 
the  large  intestine,  was  not  apparent;  it  arose  either  from  some 
laceration  of  muscular  fibre  of  the  psoas  and  subsequent  suppuration; 
or  it  occurred  as  one  of  the  secondary  deposits  in  pyaemia.  It  is 
exceedingly  improbable  that  the  vein  was  primarily  lacerated ;  we 
are  rather  disposed  to  believe  that  ulceration  perforated  its  coats. 
The  extension  into  the  colon  was  evidently  from  without,  the  larger 
size  of  the  ulcer  on  the  external  aspect,  and  the  sudden  discharge  of 
blood  by  stool,  showed  this  to  have  been  the  case. 

CASE  CLXXVII.  Abscess  in  the  Hypogastric  region  of  the  Abdominal 
JParietes,  simulating  Ovarian  Disease.  Recovery. — Emma  N — ,  aged  about 
25,  a  cook,  was  admitted  under  my  care  into  Guy's  Hospital,  October  13th, 
1856.  She  was  a  single  woman,  and  had  enjoyed  good  health  till  twelve 
months  previously,  when  she  had  violent  pain  in  the  left  side,  which  was  said 
to  arise  from  inflammation  of  the  uterus,  and  she  was  leeched,  poulticed,  and 
blistered.  Three  weeks  before  admission  a  swelling  was  perceived  in  the  left 
iliac  region,  which  was  exceedingly  tender  on  pressure. 

On  admission,  at  the  lower  part  of  the  abdomen,  between  the  hypogastric 
and  left  iliac  regions,  a  hard,  unyielding  tumor  was  detected,  which  was 
slightly  tender  and  painful  on  pressure  ;  it  extended  obliquely  towards  the 
median  line  of  the  abdomen,  and  appeared  to  be  beneath  the  muscles ;  there 
was  no  redness  of  the  skin,  and  the  pain  was  only  manifested  on  pressure. 
It  appeared  closely  to  resemble  an  ovarian  tumor.  There  was  no  febrile 
disturbance  and  the  skin  was  moist;  rest  was  enjoined,  and  the  infusion  of 
roses  with  magnesia  was  prescribed. 

Ten  days  after  admission  the  tumor  became  more  painful,  and  on  the  27th 
the  skin  slightly  inflamed ;  leeches  were  applied,  and  cataplasms,  &c. 

November  2d.  The  character  of  the  tumor  was  now  manifest,  fluctuation 
was  distinct,  the  pain  superficial,  but  severe.  On  the  4th,  the  abscess  was 
opened  by  my  colleague,  Mr.  Forster,  and  a  pint  of  pus  was  evacuated.  The 
abscess  slowly  healed,  and  on  the  23d  she  left  the  hospital  convalescent. 

CASE  CLXXVIII.  Suppuration  external  to  the  Right  Kidney.  Fibroid 
Thickening  of  the  Tunic  of  the  Kidney.  Chronic  Pyelitis.  Obliteration  of 
the  Vena  Cava.  Adhesion,  thinning,  and  doubtful  Perforation  of  the 
Ascending  Colon — Hugh  M — ,  set.  36,  was  admitted  September  12th,  1855. 
Six  months  previously  he  had  received  a  blow  on  his  back,  and  suffered 
directly  afterwards  from  hrematuria ;  this  discharge  of  blood  continued  for 
three  weeks,  and  severe  pain  in  the  back  came  on.  The  pain  continued, 
and  gradually  a  swelling  formed  in  the  loins  to  the  right  of  the  spine.  After 
the  blow  he  had  several  rigors,  and  some  febrile  excitement.  The  abscess  in 
the  loins  was  opened  on  November  26th,  and  from  that  date  continued  to 
discharge  freely.  He  was  a  man  of  middle  stature,  with  long  thin  hair,  and 
had  a  haggard  and  cachectic  appearance.  The  urine  contained  much  mucus. 
Stimulus  and  steel  were  prescribed. 

November  22d.  He  had  gradually  emaciated,  but  enjoyed  his  food  ;  his 
bowels  were  regular,  his  tongue  very  clean  ;  he  had  had  swelling  and  ]  ain 
in  his  right  leg  for  two  weeks.  On  December  19th,  the  abdomen  and  lower 
extremities  were  much  swelled ;  the  vessels  on  the  surface  were  pronnnent. 
and  the  larger  capillaries  of  the  skin  intensely  injected,  as  if  new  vessels 
had  been  formed  ;  the  skin  was  shining,  white,  and  tense.  He  was  in  con- 

TT          1          J 

siderable  distress,  and  very  prostrate,  though  not  in  severe  pain.     He  had  a 
rather  troublesome  cougk.     His  strength  gradually  failed,  and  he  sank. 
31 


482          PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT. 

On  inspection,  January  7th,  the  abdomen  only  was  examined.  The 
oedema  of  the  lower  extremities,  and  the  congestion  of  the  vessels  had  disap- 
peared. The  peritoneum  contained  about  four  quarts  of  clear  serum  ;  it  was 
smooth  and  shining,  except  on  the  peritoneal  surface  of  the  bladder,  and  in 
the  right  iliac  fossa,  where  it  was  opaque  and  covered  by  numerous  granules, 
from  about  the  size  of  a  pin's  head  to  a  pea. 

The  stomach  and  ileum  were  healthy  ;  but  the  lower  part  of  the  latter  was 
of  a  gray  color.  The^vhole  of  the  caecum  and  ascending  colon  were  of  a  deep 
iron-gray,  and  contained  much  irregular  pigment  in  the  substance  of  the 
mucous  membrane.  The  caecum  and  ascending  colon  were  so  firmly  adhe- 
rent, and  their  walls  so  thinned  posteriorly,  that  they  gave  way  on  removing 
them,  even  if  they  were  not  already  in  communication  with  the  abscess 
behind  them,  which  was  probably  the  case.  The  whole  of  the  peritoneum 
and  sub-peritoneal  tissue  around  the  right  kidney  to  the  aorta  was  much 
thickened,  semi-cartilaginous,  and,  formed  the  boundaries  of  a  sinus  filled  with 
pus ;  this  communicated  with  the  opening  made  in  the  loins,  and  extended 
down  as  low  as  the  pelvis.  The  aorta  was  normal  ;  the  vena  cava,  about  two 
inches  from  the  liver,  was  completely  occluded  by  the  thickened,  and  by  the 
fibrinous  external  deposit;  its  walls  were  irregular,  puckered,  and  it  con- 
tained a  firm  clot.  The  right  renal  vein  was  obliterated,  but  the  artery  was 
normal.  The  left  kidney  was  hypertrophied,  the  right  kidney  and  the  ureter 
contained  opaque  concrete  pus,  distending  the  calyces ;  the  secreting  struc- 
ture was  destroyed,  and  surrounded  by  a  dense  fibrous  envelope.  The  blad- 
der was  small,  thickened,  and  its  mucous  membrane  irregularly  granular. 
The  dense  tissue  about  the  right  kidney  involved  the  right  semilunar  gan- 
glion ;  it  could  with  difficulty  be  dissected  ;  the  cells  contained  a  considerable 
quantity  of  pigment,  and  their  nuclei  were  indistinct. 

The  blow  on  the  loins  produced  in  this  instance  hsematuria;  and 
led  to  abscess,  and  to  chronic  disease  of  the  kidney.  The  new  tissue 
had  become  fibrous,  and  exceedingly  dense  ;  the  ascending  colon  was 
adherent,  and  apparently  perforated,  so  as  to  communicate  with  the 
abscess ;  but  no  fecal  discharge  took  place  from  the  back,  nor  was 
there  any  evidence  of  purulent  evacuation  from  the  bowels.  The 
superficial  abdominal  veins  were  intensely  congested,  evidently  from 
obstruction  of  the  cava. 

CASE  CLXXIX.  Fecal  Abscess  in  the  Pelvis,  communicating  with  the 
Ovary  and  Bladder,  opening  twice  into  the  Rectum,  and  in  the  Groin. — Sarah 
Y — ,  «aet.  24,  residing  in  Lambeth  Road,  was  admitted  August.  22d.  Till 
nine  weeks  before  admission  she  enjoyed  good  health,  and  at  that  time,  on 
going  to  breakfast,  was  seized  with  sickness,  and  with  great  pain  in  the  abdo- 
men ;  after  a  few  days  she  had  rigors  for  three  or  four  hours,  and  the  pain, 
vomiting,  and  purging  continued  for  seven  or  eight  days  more ;  she  then 
became  more  comfortable,  and  improved  in  health  ;  one  week  before  admis- 
sion she  was  again  attacked  with  vomiting,  pain,  and  purging ;  and  these 
symptoms  continued  for  three  or  four  days.  On  admission  her  countenance 
was  Hushed,  there  was  great  pain  in  the  abdomen,  and  intolerance  of  pres- 
sure ;  the  countenance  was  anxious,  and  there  was  general  tremor.  The 
pain  continued  very  severe  till  her  death,  and  the  diarrhoea  was  persistent ; 
for  some  days  the  motions  appeared  to  be  of  a  purulent  character.  A  few 
days  before  death  a  feculent  abscess  opened  in  the  right  groin  below  Poupart's 
ligament. 


PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT.          483 

On  inspection,  the  thoracic  viscera  were  healthy;  there  were  some  pleuritic 
adhesions,  but  no  tubercle. 

Abdomen — The  general  cavity  of  the  peritoneum,  except  in  the  pelvis, 
appeared  healthy ;  the  viscera  were  collapsed  ;  the  small  intestine  was  adhe- 
rent to  the  brim  of  the  pelvis,  and  to  the  caecum. 

The  stomach  was  pale,  but  on  microscopical  examination  it  was  found  to 
be  healthy.  The  small  intestines  were  healthy  ;  the  colon,  as  far  as  the  sig- 
moid  flexure,  was  much  contracted,  and  contained  small  scybalous  grains, 
firmly  attached  to  the  mucous  membrane  of  the  intestine.  The  viscera  of  the 
pelvis  were  found  to  be  firmly  united  by  adhesions.  On  taking  out  the  uterus 
some  superficial  ulceration  was  found  at  the  os  uteri ;  the  left  ovary  and  tube 
were  normal ;  but  on  the  right  side,  at  the  position  of  the  Fallopian  tube  and 
ovary,  was  a  sac  capable  of  holding  about  £ij  of  fluid,  filled  with  purulent  and 
feculent  secretions  ;  the  abscess  communicated  by  an  irregular  opening  with 
the  first  part  of  the  rectum,  and  extended  into  an  irregular  abscess,  containing 
feces,  situated  between  the  ovary  and  rectum.  This  abscess  passed  down- 
wards towards  the  bottom  of  the  pelvis,  and  opened  again  into  the  rectum  by 
a  small  circular  opening  about  three  inches  above  the  anus :  its  boundaries 
were  exceedingly  irregular,  burrowing  beneath  the  pelvic  fascia ;  it  extended 
to  the  bladder,  and  had  perforated  its  fundus  by  a  circular  opening ;  it  also 
passed  upwards  to  the  psoas  muscle,  and  reached  the  crest  of  the  ilium  ;  below 
it  passed  beneath  Poupart's  ligament,  and  at  Scarpa's  triangle  formed  a  large 
ulcerated  opening,  about  two  inches  in  diameter.  The  mucous  membrane  of 
the  rectum  was  congested  and  gray  ;  its  calibre  at  the  part  between  the  two 
openings  was  diminished.  The  bladder  was  small,  and  its  mucous  membrane 
was  red,  but  the  cavity  did  not  contain  any  feces,  nor  did  it  appear  that  any 
had  passed  by  the  urethra.  The  kidneys  and  spleen  were  healthy  ;  the  liver 
was  tatty,  moderate  in  size  ;  its  weight  2  Ibs.  7  oz. 

In  this  case,  inflammation  appeared  to  have  commenced  in  the 
right  ovary ;  suppuration  and  local  peritonitis  followed ;  communi- 
cation then  took  place  with  the  rectum;  fecal  abscess  was  the  result; 
this  burrowed  beneath  the  pelvic  fascia,  and  formed  a  second  opening 
into  the  rectum,  one  into  the  bladder,  and  along  the  psoas  muscle  it 
reached  the  skin  upon  the  thigh. 

The  diarrhoea  proved  to  be  tenesmus  with  purulent  discharge, 
and  is  an  indication  of  one  of  the  fallacies  in  the  diagnosis  of  dysen- 
tery. There  was  some  ulceration  at,  the  os  uteri.  The  severe  pain 
arose  partly,  I  doubt  not,  from  pressure  on  the  nerves  in  the  psoas 
muscle,  namely,  the  ilio-hypogastric,  ilio-lumbar,  and  last  dorsal 
nerve,  and  from  the  attacks  of  local  peritonitis. 

CASE  CLXXX Abscess  external  to  the  Rectum  leading  to  Perforation. 

Considerable  Fibrous  Thickening,  and  Simulation  of  Cancerous  Disease — 
Ann  C — ,  aet.  55,  a  needlewoman,  living  at  Bermondsey,  was  admitted  into 
Guy's  Hospital,  March,  1857.  She  had  been  married  eighteen  years,  and 
had"  had  one  child.  Till  ten  years  before  admission  she  had  enjoyed  good 
health,  when  she  fell  and  struck  the  sacrum  ;  she  suffered  much,  and  was  con- 
fined to  her  bed :  from  that  time  there  had  been  a  constant  discharge  from 
the  rectum,  with  pain  in  defecation,  and  she  had  been  unable  to  stand  or 
walk  on  account  of  the  pain.  Three  years  later  she  was  supposed  to  have 
inflammation  of  the  uterus ;  but  the  catameriia  had  continued  regularly  till 
thirteen  months  before  admission.  For  three  or  four  months  the  left  leg  had 
been  swollen,  and  for  two  months  the  abdomen  had  been  tense  and  painful. 


484         PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT. 

She  was  a  small  delicate  woman  ;  the  abdomen  was  tense  and  tympanitic. 
The  chest  was  normal,  and  the  heart  feeble.  There  was  a  constant  discharge 
of  mucus  and  slimy  secretion  from  the  rectum  ;  and  its  calibre  was  much  con- 
tracted. The  urine  was  albuminous.  Her  strength  gradually  became  ex- 
hausted, and  she  died  in  a  few  weeks. 

The  walls  of  the  rectum  were  exceedingly  rigid,  dense,  and  fibrous,  and 
communicated  with  an  abscess,  or  rather  sinus,  on  the  concavity  of  the  sacrum. 
This  chronic  inflammatory  action  had  extended  to  the  neighboring  parts,  and 
led  to  stricture. 

During  life  this  was  supposed  to  have  been  a  case  of  cancerous 
disease,  but  the  post-mortem  inspection  did  not  confirm  this  sup- 
position ;  it  showed  that  inflammation  commenced  after  the  fall  in 
the  cellular  tissue  external  to  the  bowel,  and  led  to  the  dense  fibrous 
constriction.  This  condition  of  rectum  leads  to  abundant  discharge 
of  mucus,  simulating  diarrhoea  or  dysentery.  A  similar  state  of 
rectum  was  observed  in  a  case  under  my  own  care,  associated  with 
albuminuria ;  there,  however,  limited  to  the  walls  of  the  rectum, 
and  not  as  here  produced  by  external  inflammation.  This  case  is 
another  evidence  of  the  severity  of  pain  when  the  inferior  portion  of 
the  rectum  is  diseased,  as  compared  with  the  immunity  from  it,  in 
disease  of  the  sigmoid  flexure.  The  nerves  are  more  easily  com- 
pressed, and  the  outlet  is  also  freely  supplied  with  nerves  of  sensation. 
In  this  instance  colotomy  might  have  been  attended  with  considerable 
benefit. 

CASE  CLXXXI. — Multilocular  Ovarian  Tumor.  Perforation  of  the 
Ccecum.  Fecal  Abscess.  Pneumonia.  Pus  in  the  Ovarian  Veins — Martha 
L — ,  set,  33,  was  admitted  into  Guy's  Hospital,  December  12th,  1855.  She 
was  a  married  woman,  who  had  resided  at  Poplar.  She  had  had  five  chil- 
dren, and  the  youngest  was  fourteen  months  old  at  the  period  of  her  admis- 
sion ;  but  before  the  birth  of  her  child,  she  had  had  pain  occasionally,  of  a 
severe  character,  in  the  left  iliac  region.  After  parturition,  swelling  of  the 
abdomen  increased,  but  with  scarcely  any  pain  for  a  time,  till  the  exertion  of 
walking  produced  it  severely  ;  she  stated  that  the  tumor  fell  from  side  to  side. 
Four  months  before  admission  great  pain  came  on  in  the  left  iliac  region, 
extending  to  the  hypochondrium  of  the  same  side.  The  abdomen  afterwards 
increased  much  in  size,  and  the  catamenia  ceased.  She  had  also  suffered 
from  diarrhoea. 

On  admission  she  was  pale,  her  countenance  was  expressive  of  anxiety; 
the  mind  was  active.  The  abdomen  was  swollen  and  tense,  and  the  skin 
about  the  umbilicus  was  red  and  inflamed ;  there  was  dulness  on  percussion 
in  each  iliac  region,  but  especially  on  the  left  side,  and  on  that  side  a  tumor 
could  be  felt  extending  towards  the  loins.  The  abdomen  was  tympanitic  at 
the  umbilicus,  and  for  a  short  distance  on  either  side.  The  urine  was  high 
colored,  and  contained  lithates.  The  bowels  were  relaxed  ;  there  was  nausea 
with  loss  of  appetite.  She  was  ordered  Dover's  powder  three  times  a  day,  a 
blister  to  be  applied  to  the  abdomen,  and  milk  diet.  The  diarrhoea  became 
persistent,  and  was  with  difficulty  checked.  On  December  20th,  paroxysmal 
pain  in  the  back  came  on,  and  the  abscess  at  the  umbilicus  had  broken  and 
discharged  feculent,  with  relief  to  the  patient;  opium  and  chloroform  were 
given.  The  fecal  discharge  through  the  parietes  continued  till  death,  which 
was  preceded  by  an  aphthous  condition  of  the  mouth,  by  violent  retching  and 


PERFORATION  OF  THE  INTESTINE  FROM  WITHOUT.    485-, 

vomiting,  and  by  aggravation  of  pain  in  the  abdomen.     She  lingered  till 
February  5th. 

On  inspection,  acute  pleuro-pneumonia  was  found  at  the  base  of  the  right 
lung.  In  the  abdomen,  the  stomach  and  transverse  colon  were  found  mode- 
rately distended  ;  and  reaching  from  the  umbilicus  to  the  pelvis  was  a  tumor, 
composed  of  ovarian  cysts ;  it  was  connected  with  the  left  ovary,  and  filled 
the  left  iliac  fossa  in  front  of  the  sigmoid  flexure.  On  cutting  down  the 
median  line,  an  abscess  was  opened  extending  to  the  right,  into  the  caecum, 
the  anterior  surface  of  which  was  destroyed.  The  abscess  was  formed  in 
front  by  the  anterior  abdominal  parietes,  which  had  become  perforated ;  to 
the  left  by  the  ovarian  tumor  ;  to  the  right  by  the  caecum  and  kidney  ;  below, 
by  the  fundus  of  the  uterus,  and  by  the  rectum.  The  walls  of  the  abscess 
were  covered  with  lymph,  and  the  cavity  contained  feces.  The  ovarian 
growth  was  six  to  eight  inches  in  diameter,  composed  of  cysts,  some  capable 
of  holding  several  ounces  of  fluid,  others  almost  microscopic ;  the  fluid  was 
tenaceous  and  gelatinous  ;  and  the  walls  of  the  cyst  were  vascular  ;  near  the 
caecum  one  of  these  cysts  appeared  to  be  connected  with  the  abscess.  The 
large  ovarian  veins  extending  into  the  tumor  were  filled  with  thin  pus.  The 
right  ovary  was  small  and  atrophied.  The  uterus  was  healthy.  The  mucous 
membrane  of  the  caecum  and  ileum  were  much  congested.  The  stomach  was 
pale,  and  presented  gastric  solution  at  its  greater  curvature.  The  liver,  kid- 
neys, spleen,  and  mesenteric  glands  were  healthy. 

The  ovarian  disease  was  the  commencement  of  the  fatal  affection  ; 
one  of  its  cysts  had  become  adherent  to  the  caecum,  and  had  led  to 
perforation;  local  peritonitis  and  fecal  abscess  followed.  As  to  the 
ovarian  disease,  it  was  of  the  ordinary  multilocular  character.  The 
diagnosis  of  ovarian  disease  was  not  certain  ;  movable  carcinomatous 
tumors  become  developed  in  the  omentum;  and  the  position  of  the 
growth  was  at  first  that  presented  by  diseased  glands  about  the  kid- 
ney; it  extended  less  into  the  loins,  however,  than  is  usual  in  the 
latter  disease.  The  local  peritonitis  and  perforation  of  the  intestine 
were  evident;  and  the  treatment  most  likely  to  afford  partial  relief 
was  that  adopted,  namely,  the  administration  of  opiates  and  of  nour- 
ishment to  sustain  the  patient. 

CASE  CLXXXII.  Ovarian  Tumor  filled  with  Feces  and  opening  into  the 
Ileum.  Pneumonic  Phthisis — Catherine  S — ,  set.  47,  was  admitted  into 
Guy's  Hospital,  December  14th,  1853,  and  died  March  23d,  1854.  She  had 
been  a  washerwoman,  and  had  resided  at  Clapham.  For  sixteen  years  the 
abdomen  had  gradually  enlarged,  but  she  had  followed  her  occupation  till  five 
months  before  her  death,  when,  during  menstruation,  she  took  cold,  and  suf- 
fered from  pain  in  the  abdomen.  On  admission  there  was  severe  pain  in  the 
wholo  of  the  abdomen,  with  loss  of  appetite,  thirst,  and  want  of  sleep.  The 
countenance  was  pale  and  anxious;  the  tongue  was  brown  ;  the  skin  was  hot 
and  dry.  Ovarian  disease  could  not  be  detected  by  vaginal  examination. 
Symptoms  of  pneumonic  phthisis  and  pleurisy  came  on,  and  she  died  about 
three  months  after  admission. 

On  inspection,  the  left  pleura  was  found  full  of  pus;  the  right  lung  con- 
tained  a  vomica,  and  presented  indurated  lung  tissue  around  it.  Peyer's 
glands  were  ulcerated.  In  the  caecum  was  a  small  ulcer,  and  another  was 
found  in  the  appendix,  which  contained  feces.  The  right  ovary  was  diseased, 
and  constituted  a  cyst,  five  inches  in  diameter,  with  thickened  walls.  The 
cyst  was  firmly  adherent  to  the  lower  part  of  the  ileum,  and  communicated 


486          PERFORATION    OF    THE    INTESTINE    FROM    WITHOUT. 

with  the  intestine.  It  was  filled  with  feces,  and  was  adherent  to  the  uterus 
at  the  lower  part.  The  left  ovary  was  atrophied  ;  the  cervix  of  the  uterus 
was  enlarged  and  thickened  ;  the  kidneys  were  pale ;  and  the  liver  was  fatty. 

The  commencement  of  the  affection  strongly  indicated  ovarian  dis- 
ease ;  suppuration  took  place  around  the  ovary,  and  led  to  symptoms 
resembling  peritonitis ;  pus  was  probably  discharged  by  the  bowel. 
Inflammatory  disease  was  afterwards  developed  in  the  lung,  and  led 
to  a  fatal  termination. 

CASE  CLXXXIII. — The  following  is  one  of  a  very  unusual  char- 
acter, and  the  preparation  is  in  the  Guy's  Museum,  Nos.  2516  and 
2517. 

Extra-Uterine  Fcetation  opening  into  the  Si ff moid  Flexure. — Elizabeth 
H — ,  aged  about  20,  had  led  an  irregular  life,  and  had  had  a  child  eighteen 
months  previous  to  admission  ;  she  was  not  aware  that  she  was  pregnant ; 
she  had  been  ill  for  six  months,  but  had  only  been  confined  to  her  bed  for 
three  or  four  weeks.  She  was  in  a  state  of  extreme  prostration,  and  had 
obstinate  diarrhoea ;  the  evacuations  consisted  of  blood  and  pus ;  there  was 
slight  tenderness  of  the  abdomen,  some  fulness,  but  no  defined  tumor.  She 
died  in  sixteen  days. 

Inspection — Abdomen — In  the  pubic  region  there  were  firm  adhesions, 
and  there  was  a  cavity  bounded  by  the  ascending  colon,  and  by  the  lower 
part  of  the  sigmoid  flexure ;  posteriorly,  by  the  rectum  and  sacrum ;  ante- 
riorly, by  the  parietes,  by  the  pubes  and  bladder ;  and  laterally  by  the  pelvis. 
This  cavity  was  filled  with  pus,  and  contained  a  decomposing  foetus  about 
three  months  old.  There  were  traces  of  placenta ;  and  extending  into  the 
sigmoid  flexure  was  an  opening  two  to  three  inches  in  length  and  one  in 
breadth.  The  uterus  was  small,  and  no  decidua  was  present  it. 

In  the  'Guy's  Reports'  of  1838,  Dr.  Bright  records  a  remarkable 
case  of  abscess  of  the  spleen,  which  perforated  the  colon;  the  diagno- 
sis was  exceedingly  obscure. 

The  patient  was  a  young  woman,  aged  twenty-five,  much  emaci- 
ated, of  peculiarly  sallow  complexion  and  anxious  countenance;  she 
had  great  uneasiness  and  pain  in  the  abdomen,  particularly  at  the 
scrobiculus  cordis  and  right  hypochondrium;  food  increased  the  pain; 
the  vomiting  was  constant,  sometimes  directly  after  food  had  been 
taken ;  there  was  also  occasional  bilious  vomiting ;  the  tongue  was 
dry  and  glossy,  and  she  gradually  sank.  On  inspection,  the  lungs 
and  heart  were  found  to  be  healthy;  the  liver  was  hard  and  granular; 
the  lower  part  of  the  spleen  was  occupied  by  an  abscess,  which  was 
firmly  adherent  to  the  transverse  colon,  and  had  opened  into  it. 
There  was  also  an  abscess  in  the  left  ovary. 


487 


CHAPTER   XYIII. 

INTESTINAL  WORMS. 

THE  observations  of  late  years  have  brought  to  light  many  facts 
connected  with  intestinal  worms,  especially  as  to  their  developmental 
changes.  Since  the  translation  of  Kitchen meister's  work  by  Dr.  Lan- 
kester  for  the  Sydenham  Society,  and  of  Von  Siebold's  treatise  by 
Professor  Hnxley,  the  knowledge  of  entozoa  has  been  advanced  by 
various  observers,  but  especially  by  the  elaborate  treatise  of  Dr. 
Cobbold  in  1864 ;  and  to  this  latter  work  and  to  the  excellent  con- 
tribution of  Heller  in  Ziemssen's  'Encyclopaedia,'  1  must  refer  for  the 
full  description  of  the  several  forms  of  intestinal  worms.  These  en- 
tozoa are  of  different  kinds,  but  those  which,  from  their  resemblance 
to  portions  of  white  tape,  have  been  designated  tapeworms  are  the 
most  numerous.  The  order  Cestoda  comprises  numerous  varieties 
of  tapeworm  or  tsenia,  and  several  of  them  have  only  been  found  in 
the  human  subject. 

Teenia  soliurn. 

Toenia  medio-canellata  (T.  saginata.) 

Toenia  nana. 

Tasnia  flavo-punctata. 

Taenia  elliptica  (T.  cucumerina.) 

Bothriocephalus  latus. 

Bothriocephalus  cordatus. 

Each  tapeivorm  is  a  chain  of  living  segments  forming,  as  they  have 
been  designated,  a  colony  of  animals;  they  do  not  possess  any  mouth 
or  true  vascular  system,  but  the  nutrition  is  by  imbibition.  The  head 
of  the  animal,  scolex,  is  small,  and  it  has  two  to  four  suckers,  in 
most  varieties  with  a  coronet  of  booklets,  and  connected  with  it  are 
the  segments  of  the  body  (strobiles),  of  a  tape-like  form,  which  grad- 
ually attain  their  full  sexual  development.  The  head  is  small,  about 
half  the  size  of  a  pin's  head  ;  this  is  joined  to  the  rest  of  the  body  by 
a  neck,  which  soon  becomes  divided  into  segments,  which  vary  in 
size,  at  first  small,  one  eighth  of  an  inch  in  breadth  and  a  quarter  to 
half  an  inch  in  length,  but  they  gradually  increase  in  breadth  as  they 
pass  downwards  till  they  become  about  a  quarter  of  an  inch  in  length 
and  nearly  half  an  inch  in  breadth.  The  lower  border  of  each  seg- 
ment is  larger  than  the  upper,  and  in  this  way  the  segments  are  ap- 
plied, the  lower  one  fitting  against,  and,  as  it  were,  into  the  upper, 
thus  forming  an  irregularly  jointed  band.  Each  fully  developed  seg- 
ment contains  both  male  and  female  sexual  organs,  the  genital  open- 
ing being  a  slightly  raised  projection  at  the  side  or  upon  the  central 
surface  of  the  animal.  These  structures  are  seen  as  branching  ves- 
sels in  the  segments.  The  development  takes  place  by  the  budding 


488  INTESTINAL    WORMS. 

of  these  segments,  the  number  of  segments  increase,  and  each  has 
independent  germs  of  new  life.  The  ova  are  very  numerous,  and 
globular  or  elliptical  in  form.  The  embryos  have  three  pairs  of 
booklets,  but  do  not  at  once  form  the  tsenia,  but  having  entered  into 
the  stomach  of  another  animal  with  the  food,  they  begin  to  develop, 
passing  into  the  blood  or  into  the  vessels  and  attaining  a  cystiform 
state,  are  known  as  hydatids.  The  hydatid  reaches  its  further  state 
of  complete  development  only  after  subsequent  admission  into  a  dif- 
ferent animal.  Thus,  the  ova  of  the  tasnia  coenurus  in  a  dog  become 
in  sheep  the  hydatid  known  as  ccenurus  cerebralis,  whilst  these  hyda- 
tids, if  eaten  again  by  a  dog,  become  the  taenia  coenurus.  The  hyda- 
tids, or  ecchmococci,  that  are  so  frequently  seen  in  human  subjects, 
are  not  from  the  taenia  solium,  the  common  tapeworm,  but  the  im- 
perfect developmental  stage  of  the  taenia  ecchinococcus  which  is 
found  in  dogs,  and  has  been  found  in  those  animals  as  a  small  taenia 
with  four  joints,  and  about  a  quarter  of  an  inch  in  size.  The  taenia 
solium  has  its  early  stage  in  the  cysticercus  of  the  pig — measly  pork 
— the  cysticercus  of  the  cow  becomes  the  tsenia  medio-canellata. 
The  larval  or  hydatid  stage  presents  a  head,  as  in  the  adult  form, 
but  is  a  mere  cyst,  and  the  head  may  be  retracted  into  it.  The  head 
presents  a  projection  or  rostellum  with  four  suckers,  and  with  coro- 
net of  booklets  in  the  sexually  mature  tsenia. 

The  Tsenia  solium  is  the  most  common  form  of  tapeworm  in 
England ;  it  is  found  in  the  small  intestine,  and  is  generally  single 
and  attains  to  seven  or  even  ten  feet  in  length.  The  head  can  easily 
be  recognized  on  careful  examination,  and  is  about  the  size  of  an 
ordinary  small  pin's  head;  about  six  inches  from  the  head  the  seg- 
ments become  distinct,  and  soon  attain  their  full  development.  The 
head  has  four  circular  suckers,  and  placed  on  a  projection  or  rostel- 
lum is  a  double  circle  of  booklets.  The  segments,  proglottides,  are, 
as  we  have  before  said,  hermaphrodite;  there  are  openings  of  the 
sexual  organs  on  alternate  sides,  the  oviducts  forming  the  greater 
part  of  the  animal.  The  ova  are  produced  in  immense  numbers, 
they  are  globular  in  form,  and  are  about  ^^th  of  an  inch  in  dia- 
meter. It  is  these  ova  which  become  the  cysticercus  cellulosa  in 
the  pig.  Kiichenmeister  produced  in  man  the  tsenia  solium  directly 
from  the  cysticercus  cellulosa  of  a  pig;  he  administered  the  embryos 
to  a  man  three  days  before  his  execution,  and  afterwards  found 
several  taeniae  in  the  intestine.  Ziemssen,  quoting  Leuckart,  men- 
tions a  case  in  which  a  young  man  swallowed  of  his  own  accord  four 
embryos  of  cysticercus  cellulosa,  and  four  months  afterwards  passed 
segments  of  the  tapeworm,  and  after  medicine  had  been  given  two 
perfect  specimens  of  the  taenia  soliurn.  This  tapeworm  occasionally 
presents  irregularities  in  form  from  the  union  of  segments  or  of  two 
worms. 

The  Tsenia  medio-canellata  or  sayinata  is  a  larger  worm,  and  less 
transparent  than  the  taenia  solium;  the  segments  are  also  broader; 
the  head  has  no  rostellum  nor  booklets,  but  in  the  centre  of  the 
head  are  four  suckers  which  are  firmer  and  of  a  deeper  color  than 
in  the  taenia  solium.  The  uterus  is  more  finely  divided;  there  are 


INTESTINAL    WORMS.  489 

from  fifteen  to  twenty  dichotomous  branches.  The  ova  are  oval, 
and  rather  larger  than  those  of  the  taenia  solium,  and  the  embryos 
possess  three  pairs  of  booklets.  The  ova  cannot  be  distinguished 
from  those  of  the  tsenia  solium;  in  the  cysticercus  state  they  have 
been  found  in  the  cow  and  in  the  giraffe,  and  also  in  the  sheep,  goat, 
and  calf,  when  segments  of  the  worm  have  been  given  with  their 
food.1 

This  form  of  taenia  is  most  common  in  Africa,  but  is  also  found  in 
Northern  and  Southern  Germany. 

The  Taenia  nana  is  a  small  worm,  about  one  inch  in  length,  and 
one  fiftieth  in  breadth  ;  the  head  is  round,  and  it  has  four  disks  and 
a  single  row  of  small  booklets.  The  segments  are  about  150  in  num- 
ber, and  the  lateral  openings  are  all  on  the  same  side.  The  author 
just  quoted  states,  that  this  worm  was  found  by  Bilharz  in  Egypt  in 
great  numbers  in  the  intestine  of  a  boy  who  died  from  meningitis. 

The  Tvenia  elliptica  has  a  more  chain-like  appearance,  and  the 
head  possesses  three  or  four  rows  of  booklets.  It  has  been  found  in 
man,  but  especially  in  children,  and  also  in  dogs  and  cats. 

The  Tivnia  flavo-punctata  has  never  been  fully  described,  and  is  of 
rare  occurrence. 

The  Bothriocephalus  latus  is  the  largest  worm  which  is  known  to 
infest  human  beings,  and  it  attains  the  length  of  fifteen  to  twenty-five 
feet,  sometimes  even,  it  is  said,  as  much  as  sixty  feet.  The  head  of 
this  entozoon  is  very  different  from  those  previously  described,  as  it 
does  not  possess  any  booklets,  but  the  head,  which  is  club-shaped, 
is  deeply  grooved  on  each  side.  The  segments  are  broader  than 
they  are  long,  and  when  fully  developed  are  nearly  square.  The 
genital  pores  resemble  a  small  rosette  and  are  situated  about  the 
centre  of  the  segment,  and  they  are  all  placed  on  the  same  side  of 
the  worm.  The  eggs  are  brown  in  color  and  oval  in  form,  and  are 
provided  with  a  lid  which  separates  from  the  rest  of  the  egg.  The 
eggs  are  at  first  ciliated  and  enable  the  young  to  float  in  water ;  they 
are  in  this  state  also  possessed  of  six  booklets.  The  worm  is  gene- 
rally single,  but  there  may  be  several  of  the  same  kind,  and  other 
forms  of  taenia  are  said  to  have  been  present  with  it.  The  bothrio- 
cephalus  latus  has  been  found  in  Sweden,  in  Northwestern  Eussia 
and  Eastern  Prussia,  in  Switzerland,  and  in  Belgium  and  Holland. 

The  Bothriocephalus  cordatus  differs  from  the  last  described  worm 
in  the  form  of  its  head,  which  is  broad,  short,  and  the  grooves  are 
on  the  flat  surfaces  rather  than  on  its  margins.  The  body  com- 
mences directly  from  the  head,  and  the  segments  rapidly  increase  in 
breadth.  It  has  been  found  in  Greenland. 

The  symptoms  that  arc  produced  by  the  presence  of  tsenia  may  be 
divided  into  those  which  are  directly  connected  with  disturbance  of 
the  functions  of  the  alimentary  canal,  and  those  which  are  reflex  in 
their  character  ;  the  patient  is  generally  pale  ;  the  appetite  is  found 
to  be  unnatural,  being  variable  in  character,  and  sometimes  craving. 

1  Heller  in  'Ziemssen's  Encyclopaedia  of  the  Practice  of  Med.,'  Eng.  tr.,  vol.  vii, 
p.  717. 


490  INTESTINAL    WORMS. 

The  condition  of  the  bowels  is  also  irregular ;  there  may  be  diarrhoea 
or  constipation ;  pain  resembling  colic  is  often  complained  of,  with 
a  sense  of  exhaustion  at  the  stomach,  and  often  with  nausea  and  a 
sense  of  malaise,  but  the  only  pathognomonic  symptom  is  the  recog- 
nition of  segments  of  the  taenia,  which  are  present  in  the  evacuations. 
These  segments  may  be  single,  or  pieces  several  inches  in  length 
may  be  passed ;  but  we  have  no  security  that  the  patient  is  really 
freed  from  his  tenant  unless  the  head  of  the  animal  is  discharged. 
Other  symptoms  are  due  to  reflex  action,  as  itching  of  the  nose  and 
anus,  headache,  disturbance  of  sight,  the  sensation  as  of  ringing 
noises  in  the  ear,  sometimes  convulsion,  or  epilepsy ;  at  other  times 
pain  in  the  lirnbs  and  in  the  region  of  the  heart  may  be  produced, 
so  also  palpitation  of  the  heart. 

The  manner  in  which  human  beings  become  infested  with  these 
pests  is  by  the  introduction  of  the  ova  with  the  food.  If  meat  be 
imperfectly  cooked  the  ova  are  not  destroyed ;  thus,  imperfectly 
cooked  meat,  pork,  or  sausages,  raw  meat  or  salads,  may  be  the 
agents  by  which  the  ova  are  introduced. 

The  treatment  of  tapeworm  is  in  most  instances  one  that  leads  to 
a  satisfactory  result  in  the  expulsion  of  the  worm  ;  but,  unless  the 
head  of  the  animal  be  detected,  we  can  have  no  certainty  that  the 
pest  is  removed.  Numerous  remedies  have  been  used,  but  the  Male 
fern  is,  I  believe,  the  best ;  the  observations  made  many  years  ago 
by  Sir  William  Gull  testified  to  the  efficacy  of  this  remedy.  The 
powder  of  the  rhizome  of  the  Filix  mas  may  be  given  in  doses  of 
one  to  three  drachms,  but  a  better  preparation  is  the  liquid  extract 
or  the  oil  of  male  fern,  in  doses  of  3j  mixed  with  mucilage  mixture 
and  aromatic  water.  The  remedy  should  be  given  after  the  patient 
has  been  fasting  for  five  or  six  hours,  and  should  be  followed  by  a 
dose  of  castor  oil.  Kousso  is  another  of  these  remedies ;  it  is  the 
dried  blossom  of  the  Bray  era  anlhelmintica,  and  it  should  be  admin 
istered  when  the  patient  is  fasting.  An  infusion  should  be  made,  a 
quarter  of  an  ounce  in  four  ounces  of  boiling  water,  and  when  cool 
the  whole  quantity  should  be  swallowed.  The  remedy  is  an  effec- 
tive one,  but  very  nauseous,  on  account  of  its  smell. 

The  oil  of  turpentine  in  Jj  or  ij  doses  is  also  very  efficacious.  It 
also  should  be  given  on  an  empty  stomach,  and  at  bedtime,  for  the 
turpentine  often  produces  temporary  headache  and  giddiness. 
Kamtela  or  Kameela  is  also  recommended,1  in  doses  of  3j  or  ij,  mixed 
with  mucilage  and  followed  by  a  purgative.  The  bark  of  the  pome- 
granate root  (Granati  radicis  cortex)  is  given  in  the  form  of  decoction, 
and  often  proves  efficacious;  it  also  should  be  given  several  hours 
after  food  and  be  followed  by  a  purgative.  Other  remedies  have 
been  used,  but  those  we  have  mentioned  are  the  most  important. 
Questions  sometimes  arise  in  the  treatment  of  tapeworm  as  to  the 
propriety  of  postponing  our  remedies ;  thus  the  entozoon  is  some- 
times found  during  an  attack  of  enteric  fever,  or  during  pregnancy, 
and  the  question  arises  whether  injury  will  accrue  from  the  remedies 

1  Dr.  Gordon,  '  Report  on  Diseases  of  the  Stomach  and  Bowels  in  India.' 


INTESTINAL    WORMS.  491 

used.  In  an  instance  of  a  patient  recovering  from  enteric  fever  in 
Guy's,  under  the  care  of  the  late  Dr.  Babington,  full  doses  of  oil  of 
turpentine  were  given  without  producing  any  injurious  effect,  and 
the  patient  was  freed  from  the  taenia ;  again,  in  pregnancy  with  ex- 
cessive irritability  of  stomach  it  is  better  to  make  the  attempt  of 
cure  than  to  allow  the  patient  to  go  on  unrelieved.  Sometimes  one 
remedy  after  another  is  tried  without  success,  but  the  fault  will 
generally  be  found  to  be  in  the  mode  of  administration. 

The  Round  worms — the  Nematoda — are  more  highly  organized, 
and  there  are  several  species  which  infest  the  intestinal  canal.  One 
of  the  best  known  is  the  Ascaris  lumbricoides,  the  round  worm,  as  it 
is  termed,  varying  in  size  from  four  to  six  inches  in  the  male  to  ten 
or  fifteen  inches  in  the  female ;  it  is  cylindrical  in  form,  and  has 
three  lips  surrounding  the  mouth  of  the  animal.  The  male  is  much 
smaller  than  the  female,  and  the  spermatic  duct  opens  at  the  same 
opening  as  the  intestine,  and  two  curved  spicula  are  seen  projecting 
from  the  part.  The  female  contains  two  long  coils  of  ovary  and 
oviduct,  which  open  into  a  vagina.  The  ova  are  oval,  and  are  pro- 
duced in  immense  numbers,  and  are  expelled  with  the  feces.  They 
are  about  ^\^  to  ^\^  of  an  inch  in  diameter.  It  is  not  ascertained 
in  what  way  they  obtain  entrance  into  man,  but  they  locate  them- 
selves in  the  small  intestine,  and  often  are  very  numerous  in  the 
same  individual ;  sometimes  clusters  of  them,  two  or  three,  may 
exist  together  in  different  portions  of  the  whole  canal,  in  the  duode- 
num, jejunum,  ileum,  and  stomach  ;  I  have  seen  them  in  the  oesopha- 
gus, and  cases  have  been  described  where  they  have  produced  fatal 
results  by  getting  into  the  larynx ;  they  are  found  also  in  the  colon. 
It  has  been  stated  that  they  afe  able  to  destroy  the  coats  of  the  in- 
testine and  thus  reach  the  peritoneal  cavity ;  but  it  is  now  generally 
believed  that  ulceration  and  perforation  had  taken  place,  and  the 
lurnbricus  had  used  the  opening  thus  made;  the  irritation  they  pro- 
duce may,  however,  aggravate  ulceration  in  a  marked  degree ;  still, 
some  instances  appear  to  confirm  the  idea  that  lurnbrici  may  them- 
selves induce  ulceration  and  consequent  perforation ;  such,  for  in- 
stance, is  one  recorded  in  the  'British  Medical  Journal'  of  1861,  by 
Dr.  Sandwith,  in  which  a  small  perforation  in  the  middle  of  the 
duodenum  led  to  fatal  perforation.  Dr.  Young,  in  a  paper  in  the 
'Medical  Gazette,'  records  several  cases  where  lumbrici  were  evacu- 
ated through  the  abdominal  parietes ;  one  instance  was  in  a  child, 
aged  seven  ;  several  worms  had  been  discharged  from  the  bowels,  an 
abscess  afterwards  formed  in  the  right  lumbar  region,  and  living 
lumbrici  were  evacuated ;  after  two  years  the  abscess  healed. 

In  another  case,  a  child  aged  fifteen  had  severe  pain  in  the  abdo- 
men, and  lumbrici  were  found  in  the  stools ;  an  abscess  formed  on 
the  right  side  of  the  abdomen,  and  lumbrici  were  passed  through  it; 
on  inspection  it  was  found  that  a  fecal  abscess  had  been  formed  at 
the  commencement  of  the  colon,  into  which  also  the  jejunum  opened. 
It  is  probable  that  in  both  these  cases  either  caecal  or  strumous  dis- 
ease or  direct  injury  had  led  to  abscess,  through  which  some  of  the 
lumbrici  were  discharged.  The  same  paper  mentions  a  recorded 


492  INTESTINAL    WORMS. 

case  of  an  infant,  in  whom  a  lumbricus  was  discharged  from  the 
navel ;  and  another  of  a  woman,  in  whom  an  artificial  anus  existed 
in  the  right  groin,  through  which  a  lumbricus  was  passed.  A  worm 
crawled  from  the  mouth  of  a  young  patient  of  mine  during  the  night, 
who  had  passed  numerous  lumbrici,  after  the  administration  of 
santonine ;  the  worm  was  observed  on  the  child's  pillow.  It  is, 
however,  probable,  that  the  passage  into  the  trachea  and  bronchi 
only  takes  place  after  the  death  of  the  patient.  The  symptoms  found 
with  this  worm  are  a  tumid,  full,  and  doughy  state  of  the  abdomen, 
indicating  that  the  secretions  and  muscular  coat  are  not  in  their 
normal  condition ;  the  body  is  often  feebly  nourished ;  the  cheerful- 
ness is  lost ;  the  appetite  is  Variable,  sometimes  craving,  but  un- 
certain ;  there  is  frequently  severe  colic;  the  breath  is  offensive,  and 
there  is  irritation  of  the  nose  and  anus.  Other  signs  are  frequently 
found,  but  they  are  in  many  instances  sympathetic  from  the  irrita- 
tion of  the  intestine,  especially  when  the  subject  is  strurnous,  and 
predisposed  to  disease  in  other  viscera;  thus  the  brain  often  sympa- 
thizes, so  that  the  patient  may  be  seized  with  convulsions,  or  have 
attacks  of  chorea,  or  epileptic  fits,  conditions  which  are  entirely 
removed  by  the  evacuation  of  the  entozoa. 

These  worms  occur  more  frequently  in  young  children,  but  are 
not  limited  to  them,  for  we  observe  them  in  young  adults  of  both 
sexes,  but  especially  in  delicate  and  in  strumous  subjects. 

The  best  remedy  by  which  to  get  rid  of  the  round  worm  is  santo- 
nine, in  doses  of  3  to  5  grains  given  every  or  every  other  night  on 
an  empty  stomach.  The  santonine  is  obtained  from  an  undetermined 
species  of  Artemisia.  The  general  health  should  be  improved  by 
proper  diet  and  by  tonics,  and  the  'bowels  acted  upon  by  gentle 
aperients.  Stronger  purgatives  are  often  given,  as  jalap  and  scam- 
mony;  but,  although  they  remove  a  large  quantity  of  mucus,  they 
do  not  generally  effect  a  cure. 

The  Oxyuris  vennicularis  is  well  known  as  the  threadworm,  and 
in  its  appearance  it  closely  resembles  a  minute  portion  of  ordinary 
thread.  The  male  is  smaller  than  the  female,  and  is  about  one-sixth 
of  an  inch  in  length.  The  female  is  about  one-third  to  half  an  inch. 
The  animal  has  a  mouth  closed  by  three  lips,  from  which  extends 
the  oesophagus  and  intestinal  canal.  The  eggs  are  oval  and  about 
ssflth  to  y&nth  of  an  inch  in  size.  They  pass  all  the  stages  of  de- 
velopment in  the  intestinal  tract. 

The  threadworm  is  found  in  both  small  and  large  intestine ;  the 
mature  females  are  said  to  be  especially  found  in  the  caecum.  The 
threadworms  are  present  in  the  rectum,  and  pass  from  it  to  the 
perineum  and  even  reach  the  vagina ;  but  it  is  erroneous  to  state  that 
they  only  exist  in  the  rectum.  The  eggs  are  swallowed  with  the 
food,  and  development  begins  in  the  stomach  when  the  egg  is  acted 
upon  by  the  gastric  juice.  As  long  as  the  threadworm  exists  only 
in  the  small  or  in  the  upper  part  of  the  large  intestine  no  symptom 
is  produced,  but  in  the  rectum  its  presence  causes  intolerable  itching. 
Itching  of  the  nose,  impairment  of  appetite,  general  restlessness, 
and  distress,  may  be  produced  by  threadworms;  we  have  seen  urti- 


INTESTINAL    WORMS.  493 

caria  present  in  children  thus  affected,  but  whether  as  the  effect  of 
threadworms  is  doubtful.  They  are  more  common  in  young  child- 
ren, but  are  also  observed  in  adults. 

In  the  treatment  they  may  be  destroyed  and  washed  away  from 
the  rectum  by  means  of  enemata;  the  best  is  composed  of  one-third 
or  half  a  pint  of  lukewarm  infusion  of  quassia,  or  of  salt  and  water; 
decoction  of  oak  bark,  dilute  solution  of  alum,  may  be  also  used ;  at 
the  same  time  gentle  aperients  should  be  given,  but  such  as  will 
thoroughly  empty  the  bowel,  as  rhubarb  and  magnesia,  if  sufficiently 
active;  jalap  with  rhubarb,  syrup  of  senna,  confection  of  sulphur,  or 
a  few  grains  of  gray  powder;  afterwards  rnild  chalybeate  medicines 
may  be  administered.  The  oil  of  male  fern  and  santonine  have  less 
effect  upon  the  threadworm,  than  in  the  cases  in  which  we  have 
recommended  them.  It  is  important  to  be  very  careful  both  as  to 
the  food  taken,  and  as  to  the  perfect  cleanliness  that  should  be  ob- 
served in  every  respect. 

The  Tricocephalus  dispar,  the  whipworm,  is  a  small  worm  about 
two  inches  in  length,  with  a  thread  like  head,  the  smallest  part  of  the 
animal  constituting  about  two-thirds  of  its  length ;  it  is  generally 
found  in  the  caecum.  On  the  abdominal  surface  is  a  longitudinal  band, 
and  the  intestinal  tract  passes  throughout  the  length  of  the  animal 
from  the  oesophagus  and  the  stomach.  The  male  is  rather  smaller 
than  the  female,  and  the  male  genital  organ  presents  a  spiculum  which 
projects  from  the  cloacal  opening ;  it  is  set  with  numerous  sharp 
points,  and  is  surrounded  by  a  sheath.  The  eggs  are  oval,  they  are 
very  numerous,  and  have,  at  either  extremity,  a  minute  projection. 

We  are  not  acquainted  with  any  symptom  produced  by  the  pre- 
sence of  these  worms;  they  have  generally  only  been  recognized 
after  the  death  of  the  patient  on  post-mortem  examination.  I  have 
in  this  way  found  them,  whilst  I  had  the  charge  of  the  post-mortem 
examinations  at  Guy's  Hospital. 

The  DochmiiiSj  or  Strongylus  duodenalis,  or  the  Anchylostomum 
duodenal^  was  discovered  by  Dubini  in  1838  in  the  north  of  Italy. 
It  is  a  small  cylindrical  worm,  the  male  nearly  half  an  inch  and  the 
female  three-quarters  of  an  inch  in  length.  At  the  bell-shaped 
mouth  are  several  strong  hooks ;  the  male  terminates  in  a  lobate 
enlargement,  but  the  female  is  pointed.  The  animal  fixes  itself  in 
the  duodenum  and  jejunum;  it  is  very  common  in  Egypt,  according 
to  Bilharz.  Its  presence  produces  anaemia,  and  its  attendant  symp- 
toms of  weakness,  palpitation,  disturbance  of  the  senses;  there  is 
craving  or  depraved  appetite  and  dyspnoea.  These  symptoms  arise 
from  the  loss  of  blood. 

No  medicine  is  known  directly  to  dislodge  the  animal,  but  the 
treatment  must  be  carried  out  on  general  principles  to  remove  the 
worm  and  to  relieve  the  bloodless  condition  by  chalybeates.  Tur- 
pentine, followed  by  chalybeates,  would  be  apparently  the  best  plan 
of  treatment.  These  cases  are  not  seen  in  England,  and  I  am  depen- 
dent on  the  description  and  statement  of  other  observers. 

Several  minute  kinds  of  Trematoid  worms  have  been  recognized. 


494  INTESTINAL    WORMS. 

The  Distomum  crassum  was  found  by  Busk  in  the  duodenum  of  a 
Lascar,  and  the  Distoma  heterophyes  has  been  discovered  by  Dr. 
Bilharz  in  Egypt  in  the  intestine  of  a  boy.  The  Bilharzia  haBma- 
tobia,  also  prevalent  in  Egypt,  has  been  the  cause  of  diarrhoea  and 
hsematuria;  but  for  many  particulars  of  these  and  other  varieties 
which  have  been  noted  by  observers  we  must  refer  to  the  treatises 
already  mentioned. 


CHAPTER   XIX. 

ON  PERITONITIS. 

REFERENCE  has  frequently  been  made  in  the  preceding  chapters 
to  disease  of  the  serous  investment  of  the  intestines,  the  peritoneum : 
and  we  propose  now  to  review  the  general  forms  of  peritonitis,  to 
notice  the  pathological  appearances  they  present,  the  symptoms  by 
which  they  are  indicated,  the  causes  which  produce  them,  and  then 
the  treatment  best  calculated  for  their  removal. 

Peritonitis  is  presented  under  the  form  of  acute  or  plastic  inflam- 
mation, chronic  inflammation,  purulent  inflammation,  septic  inflam- 
mation. 

Acute  peritonitis.  The  earliest  pathological  appearance  which  the 
peritoneum  presents,  when  acutely  inflamed,  is  congestion  of  the 
capillary  vessels,  with  a  loss  of  the  smooth  and  shining  appearance 
of  the  serous  membrane;  dry  ness  then  takes  place,  from  the  dimin- 
ished secretion,  and  slight  opacity  follows.  This  congestion  is  espe- 
cially manifest  at  the  angles  of  contact  of  the  coils  of  the  intestine, 
thus  producing  vascular  lines,  which  pass  along  the  long  axis  of 
bowel ;  in  very  acute  disease,  however,  the  whole  surface  is  reddened. 
The  inflammatory  oedema  which  gives  opacity  to  the  serous  mem- 
brane is  an  indication  that  the  sub-peritoneal  coat  is  involved;  it 
arises  from  interstitial  cell-growth.  The  muscular  coat  next  partici- 
pates in  the  disease;  its  contractile  power  is  diminished,  and  the 
intestine  distends,  producing  the  tympanitis  -of  which  we  shall  have 
to  speak;  the  coats  of  the  intestine  may  be  readily  separated  from 
each  other;  effusion  of  lymph  then  takes  place,  and  it  is  often  found 
to  cover  over  the  intestine  in  large  flakes,  mixed  with  serum  in  the 
more  dependent  situations;  if  the  disease  be  at  a  very  early  stage, 
or  slight  in  degree,  this  lymph  is  represented  by  a  mere  stickiness 
and  very  slight  adhesion  between  the  intestines.  The  serum  is 
sometimes  present  in  considerable  quantities,  and  in  chronic  perito- 
nitis fills  and  distends  the  serous  sac;  but  the  conditions  of  the  fluid 
effusion  vary  according  to  the  character  and  the  intensity  of  the 
disease;  sometimes  it  consists  of  clear  serum  containing  portions  of 
semi-coagulated  fibrin;  at  other  times  the  serum  may  be  almost  of 
the  character  of  pus,  and  between  these  extremes  every  gradation 
is  observed.  In  proportion  as  the  effusion  is  less  organized  it  is 
corpuscular  in  character,  and  approaches  proportionately  to  the 
appearance  of  pus.  As  the  peritonitis  subsides,  these  effusions  may 
gradually  become  absorbed;  but  more  generally  they  leave  traces 
of  their  presence,  the  lymph  becomes  organized,  fibres  are  produced, 
and  vessels  become  developed  in  them ;  adhesions  between  portions 
of  intestine  are  thus  formed,  either  uniting  them  closely  together,  or 


496  ON    PEHITONITIS. 

constituting  bands,  which  may  be  the  cause  of  subsequent  internal 
strangulation;1  the  lymph  which  covers  the  viscera,  as  the  liver  and 
spleen,  often  forms  a  thick  investment,  which  gradually  becomes 
firm,  fibrous,  and  cartilaginous  in  density,  and  calcareous  particles 
are  occasionally  developed  in  it,  especially  in  the  splenic  adhesions; 
at  an  early  stage  these  investments  may  be  stripped  off'  from  the 
proper  tunic  of  the  viscus,  but  afterwards  they  become  inseparably 
united.  Again,  sometimes  the  lymph  is  spread  generally  upon  the 
viscera,  or  it  forms  rounded  patches,  or  it  has  a  cribriform  appear- 
ance, as  if  rounded  portions  had  been  removed  or  absorbed.  Lymph 
deposited  upon  and  between  the  layers  of  the  mesentery  and  omen- 
turn  leads  to  gradual  contraction,  to  shortening,  and  fibroid  thicken- 
ing. In  some  cases  the  serous  membrane  has  a  granular  appearance; 
these  granules  must  not  be  mistaken  for  an  appearance  sometimes 
found  several  days  after  death,  when  the  serous  membrane  appears 
sprinkled  with  grains  of  sand;  these  possess  the  crystalline  character 
of  triple  phosphate,  and  are  probably  formed  after  death.  Lastly, 
acute  peritonitis  may  lead  to  a  general  thickening  of  the  serous 
membrane  without  adhesions;  the  membrane  becomes  dense,  whitish, 
thickened,  arid  fibrous,  and  this  arises  from  the  fibrinous  effusion 
taking  place  in  the  substance  of  the  membrane  rather  than  on  its 
surface.  In  chronic  peritonitis  the  same  general  changes  are  pro- 
duced; lymph  may  be  effused,  become  organized,  and  form  adhesions 
or  produce  thickening  of  the  serous  membrane;  or  effusion  of  serum 
takes  place,  so  as  to  distend  the  serous  membrane,  even  without 
previous  acute  symptoms.  The  thickening  of  portions  of  peritoneum 
covering  the  liver  which  is  frequently  found  after  the  pressure  from 
stays  and  belts,  consists  in  part  of  a  fibroid  degeneration  of  the  serous 
membrane  itself. 

Peritonitis  is  either  general  or  local ;  the  former  is  often  rapidly 
fatal;  the  latter  is  in  many  instances  conservative  in  its  action  ;  and 
in  perforation  of  the  intestine  from  numerous  causes,  it  limits  or  pre- 
vents extravasation.  If  extravasation  have  occurred,  it  may  be  so 
localized  by  peritoneal  adhesions,  that  life  is  prolonged  for  weeks,  or 
even  for  many  months.  When  acute  inflammation  in  the  abdominal 
glands  or  viscera  takes  place,  local  disease  of  the  peritoneum  in  the 
neighborhood  is  set  up;  thus  the  peritoneum  covering  the  liver  be- 
comes involved  in  hepatic  disease,  and  that  in  the  pelvis  in  acute 
disease  of  the  ovary. 

Tubercular  peritonitis  has  already  been  described. 

Cancerous  disease  of  the  peritoneum  frequently  leads  to  inflamma- 
tory change  of  an  acute  or  chronic  form,  but  these  changes  will  be 
subsequently  referred  to;  it  occurs  either  as  a  primary  disease  of  a 
scirrhous,  medullary,  or  colloid  form,  or  as  a  secondary  one,  from  the 
extension  of -the  disease  to  the  peritoneum  from  the  intestine.  Thus, 
in  cancerous  disease  of  the  stomach,  or  of  the  caecum  and  colon,  tuber- 
cles with  inflammatory  lymph  are  often  found  upon  the  peritoneum; 

1  Bands  leading  to  strangulation  do  not  always  have  an  inflammatory  origin.  See 
an  interesting  pamphlet  on  this  subject,  by  Mr.  Gay. 


ON    PERITONITIS.  497 

so  also  with  cancerous  disease  of  the  ovaries  and  of  the  mesenteric 
and  lumbar  glands;  but  in  advanced  life  especially,  primary  cancer- 
ous disease  of  the  peritoneum  is  not  unfrequent ;  an  immense  number 
of  tubercles,  some  semi-transparent,  others  red  and  congested,  from 
the  size  of  grains  of  sand  to  split  peas,  are  found  everywhere  stud- 
ding the  serous  surface,  mixed  more  or  less  with  ordinary  fibrin  and 
lymph;  sometimes  the  deposition  of  pigment  in  these  tubercles  gives 
them  a  black  color,  and  a  form  of  rnelanosis  is  produced;  this  appear- 
ance, however,  is  to  be  distinguished  from  the  blackness  arising  from 
effused  blood.  This  form  of  cancerous  disease  is  generally  associated 
with  considerable  serous  effusion,  and  it  is  more  common  in  women 
than  in  men.  Again,  sometimes  cancerous  disease  especially  in- 
volves the  ornentum  or  the  mesentery;  and  it  is  generally,  when 
so  situated,  either  of  a  medullary  character,  constituting  large  masses, 
composed  of  nuclei  and  nucleated  cells,  or  of  a  scirrhoid  character, 
when  the  affected  parts  become  thickened  by  a  fibro-cancerous  growth ; 
sometimes  the  disease  consists  of  colloid  growth.  The  omentum 
in  these  cases,  often  forms  a  dense,  hard  mass,  extending  across 
the  abdomen  at  the  umbilical  region ;  it  is  then  several  lines  in 
breadth,  and  semi-cartilaginous,  but  still  more  or  less  transparent; 
and  serous  or  fibrinous  effusions  may  have  taken  place  in  con- 
siderable quantity  into  the  serous  sac.  In  some  cases,  both  of  minute 
cancerous  tubercles  on  the  peritoneum,  and  of  the  more  general 
thickening  to  which  we  have  just  referred,  it  is  very  difficult  to 
draw  an  exact  line  of  demarcation  between  the  simple  products  of 
ordinary  inflammation  and  those  of  true  cancerous  disease.  If  a 
large  quantity  of  pigment  be  deposited  in  the  cells  of  the  growth, 
as  we  sometimes  find  in  medullary  cancer  of  the  omentum,  &c.,  the 
term  melanotic  cancer  is  applied.  Colloid  cancer  affects  the  perito- 
neum either  in  part,  as  when  the  ornentum  only  is  affected,  or  gene- 
rally, when  it  envelops  almost  the  whole  of  the  abdominal  viscera; 
it  presents  the  semi-gelatinous  appearance  of  colloid  with  intersect- 
ing bands,  constituting  alveoli,  which  contain  large  nucleated  cells 
and  colloid  matter.  This  colloid  disease  of  the  peritoneum  is  either 
primary  or  it  follows  from  colloid  affection  of  the  stomach,  the 
caecum,  &c. 

The  symptoms  of  acute  peritonitis  are  generally  very  characteristic, 
as  when,  for  instance,  the  stomach  and  appendix  caeci  are  perforated 
by  ulceration,  sudden  intense  pain  comes  on,  the  patient  is  "doubled 
up,"  unable  to  move,  and  lies  with  the  legs  flexed;  the  countenance 
expresses  the  intensity  of  the  suffering,  as  well  as  the  serious  nature 
of  the  disease ;  the  distress  and  pain  are  evident  in  the  features,  the 
eyes  are  sunken,  the  face  is  pallid,  the  abdomen  very  shortly  becomes 
distended,  tender  and  tympanitic;  no  pressure  can  be  borne,  and 
even  the  weight  of  the  bedclothes  becomes  insufferable ;  the  pulse  is 
small,  compressible ;  and,  if  reaction  take  place  from  the  first  sudden 
collapse,  it  becomes  more  hard,  frequent  and  wiry;  the  bowels  are 
generally  confined,  especially  at  the  early  stage  of  the  acute  disease, 
but  sometimes  towards  the  close  of  the  malady  diarrhoea  may  super- 
vene. The  urine  is  scanty,  and  if  the  vesical  peritoneum  be  in- 
32 


498  ON    PERITONITIS. 

volved,  retention  often  takes  place.  If  the  peritoneal  surface  of  the 
stomach  be  implicated,  vomiting  is  a  frequent  and  distressing  symp- 
tom, and  green  bilious  fluid  is  ejected.  The  mind  may  be  conscious 
and  strong  throughout,  even  when  the  powers  of  life  are  fast  failing, 
and  the  pulse  is  scarcely  perceptible  at  the  wrist. 

In  many  cases  of  perforation  the  patient  scarcely  rallies  from  the 
first  sudden  collapse,  and  death  takes  place  in  five  to  ten  hours 
after  the  onset  of  the  disease  ;  in  other  instances,  however,  the  signs 
of  febrile  excitement,  which  are  never  well  marked  in  acute  perito- 
nitis, are  more  evident,  as  shown  by  heat  of  skin,  especially  of  the 
abdomen,  by  thirst,  and  by  a  frequent  and  hard  pulse.  If  the  dis- 
ease tend  to  an  unfavorable  termination,  the  prostration  increases, 
the  patient  is  restless,  the  tongue  dry  and  brown,  the  pulse  compres- 
sible, failing  and  irregular;  the  extremities  become  cold,  a  clammy 
sweat  breaks  out,  hiccough  comes  on,  and  then  death  follows,  the 
patient  often  remaining  sensible  till  the  close,  and  the  subsidence  of 
pain,  as  life  is  ceasing,  occasionally  gives  to  the  superficial  observer 
a  false  hope  of  recovery.  On  the  contrary,  when  the  vomiting  sub- 
sides, the  pain  and  distension  lessen,  the  countenance  becomes  less 
haggard  and  dejected,  the  pulse  soft  and  less  frequent,  but  tolerably 
firm,  and  especially,  when  the  patient  has  refreshing  sleep,  we  may 
regard  the  immediate  danger  as  less  imminent.  Gradually  all  the 
symptoms  may  disappear,  and  the  patient  completely  recover,  with 
perhaps  some  peritoneal  adhesions  and  thickening.  It  may  be  that 
effusions  take  place,  which  are  more  gradually  absorbed,  or  become 
very  persistent ;  again,  if  fecal  extravasation  have  occurred,  repeated 
attacks  of  local  peritonitis,  with  hectic  fever,  follow,  or  renewed 
general  inflammation  destroys  the  life  of  the  patient. 

It  must  be  remembered,  however,  that  pain  is  not  an  invariable 
symptom  of  peritonitis ;  sometimes  the  patient  presents  an  exhausted 
appearance,  the  tongue  is  dry  and  brown,  the  pulse  is  very  compres- 
sible, the  abdomen  is  distended,  but  no  complaint  is  made,  and  the 
patient  dies  from  asthenia  or  exhaustion,  and  on  the  post-mortem 
table  the  coils  of  intestine  are  found  to  be  covered  with  lymph,  and 
the  whole  serous  membrane  acutely  inflamed.  Such  cases  we  have 
often  seen  after  paracentesis  in  chronic  disease  of  the  liver.  Again, 
in  cases  of  pyaemia,  and  of  septic  poisoning,  acute  inflammation, 
leading  to  purulent  effusion  into  the  serous  cavity,  takes  place  with- 
out any  pain  in  many  instances.  Other  symptoms  are  present, 
distension  of  the  abdomen,  tympanitis,  sometimes  but  not  invariably, 
constipation,  and  dryness  of  the  tongue.  There  may  be  vomiting 
and  hiccough,  and  failing  pulse ;  the  mind  may  be  clear,  or  there 
may  be  delirium  and  unconsciousness  before  a  fatal  termination 
ensues. 

Chronic  Peritonitis  may  commence  with  the  symptoms  of  acute 
disease,  and  subsequently  produce  recurrent  pain,  distension  and 
effusion.  This  recurrence  of  symptoms  is  more  especially  the  case 
in  the  course  of  tubercular  and  cancerous  disease.  In  these  instances 
the  symptoms  are  less  severe,  although  of  the  same  general  char- 
acter; pain,  with  distension  and  tympanitis,  and  with  a  peculiar 


ON    PERITONTTIS. 

haggard  expression,  which  is  very  characteristic  of  abdominal  affec- 
tion; the  abdomen  is  at  the  same  time  hot,  and  tender  on  pressure. 

In  strumous  peritonitis,  the  pain  is  paroxysmal,  and  often  resembles 
severe  colic;  the  bowels  are  irregular,  the  stomach  sometimes  irrita- 
ble, the  tongue  red  and  injected,  the  patient  fretful,  and  as  the 
intestines  become  matted  together  by  adhesions,  the  viscera  move 
en  masse,  and  a  doughy  sensation  is  communicated  on  manipulation ; 
or  these  strumous  and  inflammatory  adhesions  may  be  local,  simulat- 
ing abdominal  tumors.  The  indications  of  disease  are  also  associated 
with  general  strumous  cachexia.  and  are  often  complicated  with 
pulmonary  disease.  Too  frequently  hectic  supervenes,  and  this  is 
especially  the  case  when  fecal  abscess  has  been  produced,  and  the 
hope  of  ultimate  recovery  is  then  almost  taken  away.  In  strumous 
peritonitis  also  the  pain  may  be  very  slight,  whilst  effusion  gradually 
takes  place  to  a  considerable  extent,  as  we  sometimes  find  in  children 
after  measles,  &c.,  or  excessive  tympanitis  may  be  produced  without 
any  acute  pain. 

In  cancerous  peritonitis  there  is  the  same  expression  of  distress  on 
the  countenance,  with  pain  and  heat  of  the  abdomen,  with  gradual 
distension,  and  often  with  serous  effusion;  if  the  disease  consist  in 
cancerous  growth  in  the  omentum  and  mesentery,  a  tumor  may 
generally  be  felt;  if  it  extend  to  the  peritoneum  from  the  stomach, 
liver,  intestine,  ovary,  &c.,  the  earlier  symptoms  will  be  indicative 
of  the  primary  malady.  It  must,  however,  be  remembered,  that  in 
both  strumous  and  cancerous  disease  the  symptoms  of  acute  perito- 
nitis may  be  suddenly  developed  in  the  course  of  the  chronic  disease, 
from  perforation  of  the  intestine  or  otherwise,  and  lead  to  a  speedily 
fatal  termination.  This  acute  mischief  is  sometimes  set  up  by  per- 
foration from  degeneration  of  cancerous  deposit,  or  by  paracentesis, 
the  persistent  irritation  and  congestion  of  the  serous  membrane 
passing  very  readily  into  general  and  acute  inflammation.  In  colloid 
disease  of  the  peritoneum,  the  symptoms  are  often  obscure,  they  are 
pain,  with  heat  and  more  or  less  distension  of  the  abdomen,  and 
sometimes  diarrhoea;  but  if  the  intestine  become  involved,  other 
diagnostic  symptoms  arise. 

Diagnosis. — The  pain  of  peritonitis  may  not  only  be  absent,  on  ac- 
count of  some  peculiarity  in  the  character  of  the  disease,  but  the 
patient  may  be  rendered  unconscious  of  it  from  cerebral  oppression, 
or  from  the  dyspnosa  and  distress  of  pulmonary  and  cardiac  disease 
fully  engrossing  the  sensibilities  of  the  sufferer. 

Still  there  are  painful  conditions  of  the  abdomen  for  which  perito- 
nitis may  be  mistaken.  1st.  Flatulent  colic.  The  pain  and  distension 
are  in  this  disease  sometimes  very  severe,  the  countenance  may  be 
haggard  and  distressed,  and  collapse  sometimes  results ;  but  there  is 
not  the  tenderness  of  peritoneal  inflammation,  the  symptoms  are  less 
persistent,  the  pulse  less  affected,  the  collapse  rarely  so  profound. 
2d.  In  hysterical  affections  of  the  abdomen,  the  pain  is  very  super- 
ficial, and  firm  pressure  can  frquently  be  borne,  notwithstanding 
that  the  patient  almost  shrieks  before  the  hand  has  reached  the 


500  ON    PERITONITIS. 

surface;  the  countenance  does  not  express  the  distress  of  serious 
organic  disease,  the  pulse  may  be  almost  unaffected;  still,  in  this 
disease,  we  have  seen  a  patient  bled  from  the  arm  to  syncope, 
with  the  idea  that  acute  disease  existed.  3d.  The  vomiting  and 
sudden  pain  of  perforated  intestine  are  sometimes  mistaken  for  gall- 
stone ;  but  the  latter  disease  is  free  from  the  acute  tenderness  and 
distension  of  peritonitis.  4th.  Neuralgic  pain  from  disease  of  the 
spine,  of  a  functional  or  organic  character,  often  simulates  peritonitis; 
but  here,  also,  there  is  an  absence  of  tenderness  on  pressure  of  the 
abdomen,  of  distension  and  tympanitis,  as  well  as  of  the  general  ex- 
pression of  peritoneal  disease ;  the  pain  is  situated  in  the  course  of 
the  spinal  nerves,  and  often  extends  over  the  crest  of  the  ilium  in 
the  course  of  the  last  dorsal  nerve,  or  into  the  groin  and  testicle  in 
the  course  of  the  genito-crural  nerve  ;  there  are  also,  generally,  some 
indications  of  spinal  disease  in  local  pain  of  the  vertebrae,  with  modi- 
fied motion  and  sensibility  of  the  lower  extremities,  and  loss  of  power 
of  the  sphincter  muscles.  5th.  Suppuration  of  the  abdominal  parie- 
tes  is  at  an  early  stage  very  difficult  to  distinguish  from  peritonitis. 
6th.  The  pain  from  the  distension  consequent  on  the  enlargement  of 
abdominal  tumors  and  effusions  may  easily  be  mistaken  for  perito- 
nitis, as,  for  instance,  in  aneurism,  in  ovarian  and  cancerous  tumors, 
and  in  dropsies ;  but  in  these  cases,  as  we  have  before  said,  peritoneal 
disease  is  often  set  up  in  the  progress  of  the  malady.  7th.  During 
the  course  of  peritonitis,  the  muscular  fibres  of  the  bladder  sometimes 
fail  to  contract,  apparently  from  loss  of  power,  and  the  urine  is 
retained,  thus  closely  simulating  simple  retention  of  urine;  on  the 
contrary  we  have  also  witnessed  distension  of  the  urinary  bladder 
from  enlarged  prostate  or  other  cause,  producing  pain  which  re- 
sembled peritonitis,  and  which  had  been  sent  to  the  hospital  as  a 
case  of  abdominal  tumor. 

In  reference  to  the  prognosis  of  peritonitis,  instances  of  intestinal 
perforation  are  generally  quickly  fatal,  in  from  five  to  ten  hours; 
but  in  some  cases  this  issue  might  be  prevented  if  perfect  rest  were 
maintained,  stimulants  and  purgatives  avoided,  and  opium  given ; 
for  by  movements  of  the  body  extravasation  is  increased,  and  we 
have  seen  castor-oil  floating  in  the  peritoneum  after  perforation  had 
taken  place.  In  other  cases,  we  must  be  guided  in  the  prognosis  by 
the  cause  of  the  peritonitis,  whether  it  be  of  a  remedial  character  or 
not.  As  to  those  symptoms  which  immediately  indicate  a  favorable 
or  unfavorable  termination,  we  have  already  alluded  to  them  in  de- 
scribing the  general  characteristics  of  the  disease. 

Caiisfs. — Although  peritonitis  is  spoken  of  and  treated  as  an 
idiopathic  disease,  we  do  not  find  that  it  is  so ;  it  is  excited  by  injury 
to  the  serous  membrane,  or  by  the  direct  propagation  of  disease ; 
and  to  elucidate  this  part  of  our  subject  we  have  referred  to  the  in- 
spections made  at  Guy's  Hospital  during  a  period  of  twenty-five 
years ;  out  of  3752  inspections  501  were  instances  of  peritonitis ;  but 
we  cannot  find  a  single  case  thoroughly  recorded  in  Avhich  disease 
could  be  correctly  regarded  as  existing  solely  in  the  serous  mem- 
brane. 


ON    PERITONITIS.  501 

In  relation  to  its  causes,  cases  of  peritonitis  may  be  divided  into 
three  classes.  1.  Peritonitis  produced  by  the  extension  of  disease 
from  adjoining  viscera,  or  excited  by  direct  injury,  including  cases 
of  perforation  of  viscera,  extravasation,  violence,  &c.  2.  Peritonitis 
connected  with  blood  changes,  as  when  inflammation  of  the  serous 
membrane  occurs  in  the  course  of  alburninuria,  pyaemia,  puerperal 
fever,  erysipelas,  &c.  3.  Peritonitis  caused  by  general  nutritive 
changes  of  the  system,  which  have  been  followed  by  acute  or  chronic 
disease  of  the  peritoneum,  such  as  struma,  cancer,  &c. ;  and  corn- 
prising  also  those  cases  in  which  the  circulation  of  the  peritoneum 
has  been  so  altered  by  continued  hypenemia  (modifying  its  state  of 
growth),  that  very  slight  exciting  causes  suffice  to  induce  acute  mis- 
chief, as  occurs  in  peritonitis  with  cirrhosis,  diseases  of  the  heart, 
&c.  In  reference  to  the  instances  found  amongst  the  large  number 
of  inspections  just  referred  to,  we  find — 

1.  Peritonitis  from  direct  extension         .  .     261 

2.  Peritonitis  connected  with  blood  changes        .       94 

3.  Peritonitis  connected  with  general  or  local 

perverted  nutrition   ....     146 

501 

It  will  be  evident  that  the  first  class  might  be  regarded  as  disease 
of  a  local  kind,  and  the  second  and  third  as  of  a  general  character. 
The  first  division  includes  261  instances  of  peritonitis,  and  of  these 
102  were  produced  by  hernia,  internal  and  external,  intussusception, 
bands  of  adhesion,  and  cancerous  obstruction.  In  19  cases  the  ob- 
struction was  of  an  internal  kind,  and  in  not  a  few  of  these  death 
followed  from  rupture  of  the  intestinal  coats ;  35  cases  were  caused 
by  injuries  or  operations  directly  affecting  the  serous  membrane. 
In  some  instances  of  severe  abdominal  injury,  death  resulted  before 
any  sign  of  inflammation  had  taken  place,  the  injury  being  of  such 
a  character  that  no  treatment  could  be  more  than  palliative  in  the 
most  trifling  degree,  as  when  the  jejunum  was  completely  divided 
by  a  vehicle  passing  over  the  body. 

Among  the  operations  referred  to,  one  was  for  the  removal  of  an 
ovarian  cyst ;  one  a  case  of  gastrotomy ;  fourteen  were  cases  of 
paracentesis  abdominis,  which  was  performed  in  five  patients  to  re- . 
lieve  ascites  accompanying  cirrhosis,  in  two  for  ascites  with  heart 
disease,  and  in  seven  to  empty  large  ovarian  cysts.  In  instances  of 
ascites  from  heart  disease,  chronic  bronchitis,  and  cirrhosis,  the 
whole  of  the  peritoneal  capillaries  are  in  a  state  of  continued  hyperae- 
mia;  the  serous  membrane  becomes  opaque  and  thickened,  and  a 
very  slight  fresh  exciting  cause  is  sufficient  to  produce  acute  disease. 
If  a  large  number  of  instances  of  paracentesis  abdominis  had  been 
taken,  it  would  have  been  found  that  in  ovarian  disease,  especially 
of  persons  advanced  in  life,  paracentesis  is  much  less  frequently 
followed  by  a  severe  and  fatal  result  than  in  ascites  following  cir- 
rhosis. 

Perforation  of  the   intestine  into  the  peritoneal  sac  constitutes  a 


502  ON    PERITONITIS. 

most  important  cause  of  peritonitis,  and  we  shall  briefly  notice  the 
several  varieties.  Out  of  the  501  cases  of  peritonitis  perforation 
occurred  56  times,  namely : 

10  from  hernia; 

9  from  disease  of  the  stomach ; 
15  from  ulceration  of  the  ileum  in  enteric  fever ; 
4  from  tubercular  disease; 

11  from  disease  of  the  cascum  and  appendix; 

1  from  cancer  of  the  vagina; 
4  from  cancer  of  the  colon ; 

2  from  ovarian  adhesions. 

56 

This  lesion,  so  often  fatal  in  enteric  fever,  generally  supervenes 
about  the  twenty-first  or  twenty-second  day,  and  many  instances  are 
no.  doubt  accelerated  by  muscular  movements ;  the  period,  however, 
of  perforation,  is  subject  to  considerable  variation,  occurring  some- 
times as  early  as  the  tenth  day ;  in  others,  being  postponed  till  the 
fifth  or  sixth  week,  when  the  patient  may  seem  convalescent.  We 
have  before  referred  to  the  fact,  that  in  fever,  peritonitis  is  set  up 
by  ulceration,  although  the  peritoneum  may  be  entire,  transudation 
having  taken  place  in  a  sufficient  degree  to  produce  acute  mischief. 

In  tubercular  disease  the  sudden  and  intense  peritonitis  from 
perforation  is  generally  prevented  by  adhesions ;  occasionally,  how- 
ever, these  limitations  of  the  mischief  are  incomplete;  in  the  ulcera- 
tion of  phthisis,  as  well  as  in  tubercular  disease  of  the  peritoneum, 
this  sudden  termination  is  found  to  occur. 

Diseases  of  the  caecum  and  of  the  appendix  are  still  more  frequent 
causes  of  peritonitis,  and  in  these  affections  perforation  often  takes 
place  unexpectedly.  In  perforations,  however,  of  every  kind,  the 
extravasation  may  be  circumscribed,  and  local  peritonitis  and  fecal 
abscess  be  the  result ;  numerous  instances  of  this  kind  are  detailed 
in  preceding  chapters. 

Another  frequent  source  of  peritonitis  consists  in  the  extension  of 
disease  from  the  bladder,  uterus,  and  other  pelvic  viscera ;  and  in 
less  severe  degrees  local  peritonitis  is  often  observed  from  ovarian 
irritation.  The  enumeration  of  the  pelvic  origin  of  forty-two  cases 
from  amongst  the  numbers  we  have  before  referred  to  will  best 
illustrate  the  nature  of  this  cause : 

6  from  ovarian  disease; 
1  from  ulcerated  vagina  and  uterus; 
1  from  strumous  disease  of  the  testicle  and  castration; 
1  from  diseased  prostate; 
1  from  strumous  pyelitis; 
1  from  fistula  in  ano  ; 
1  from  cancerous  disease  of  the  bladder ; 
1  from  polypus  in  the  bladder ; 
l-l  from  cystitis,  calculus  in  the  bladder,  stricture,  &c.; 


ON    PERITONITIS.  503 

1  from  extravasation  of  urine ; 

2  from  sloughing  perineum ; 

1  from  sloughing  of  the  nates  ; 
10  from  lithotomy ; 
1  from  diseased  hip  and  pelvis. 

4.2 

This  number  does  not  include  peritonitis  from  stricture  and  chrome 
ulceration  of  the  rectum  ;  diseases  which  not  unfrequently  extend  to 
the  serous  membrane.  The  introduction  of  bougies,  and  the  incau- 
tious digital  examination  of  the  bowel,  may  sometimes  lead  to  acute 
peritonitis. 

Peritonitis  is  also  caused  by  diseases  of  the  liver  and  gall-bladder, 
and  some  of  these  are  instances  of  extreme  interest ;  thus,  abscess  in 
the  liver,  hydatid  disease,  gall-stone,  primary  disease  of  the  gall-blad- 
der may  each  induce  disease  of  the  general  serous  membrane.  In 
many  cases  of  chronic  congestion  and  enlargement  of  the  liver,  and 
in  cirrhosis,  especially  of  an  acute  kind,  the  peritoneum  becomes  im- 
plicated ;  and  the  serous  membrane  is  found,  when  a  fatal  issue  has 
taken  place,  to  be  thickened  and  chronically  inflamed;  acute  peri- 
tonitis is  in  these  conditions  very  easily  induced ;  but  we  have  in- 
cluded these  chronic  forms  of  hepatic  disease  amongst  the  third  class 
of  causes  of  peritonitis. 

Peritonitis  is  sometimes  the  result  of  acute  disease  of  the  mucous 
membrane  of  the  intestine,  extending  to  the  deeper  coats,  and  to  the 
peritoneum  itself,  leading  to  inflammation,  or  to  perforation  and  fecal 
abscess.  Ulceration  of  the  colon  was  the  cause  of  fecal  abscess  in 
three  of  the  instances  we  have  previously  mentioned,  and  a  case  of 
simple  perforation  was  from  this  cause.  In  three  other  instances, 
acute  dysentery,  with  sloughing  of  the  coats  of  the  intestine,  also  pro- 
duced peritonitis. 

In  reference  to  the  etiology  of  peritonitis,  the  following  table  shows 
not  only  the  large  proportion  of  cases  due  to  simple  extension  of  dis- 
ease to  the  serous  membrane,  but  the  forms  of  disease  by  which 
peritonitis  is  induced ;  261  instances  from  501  are  thus  referable  to 
direct  extension : — 

From  hernia,  of  which  19  were  cases  of  internal  obstruction    .  .102 

"      injuries  or  operations       .  .  .  .  .  .35 

"      perforation  of  the  stomach,  ileum,  caecum  and  appendix,  colon, 

&c.  (other  13  mentioned  with  hernia  or  with  caecal  disease)    .       43 
"      perforation   leading  to  fecal  abscess   (2   cases    mentioned   else- 
where) .  .  .  .  .  .  .17 

"      typhoid  ulceration  without  perforation     .  .  .  /) 

"      disease  or  operations  on  the  bladder  and  pelvic  viscera,  &c.         .       42 
"      disease  of  liver  and  gall-bladder,  &c.       .  .  .  .11 

"      acute  disease  of  the  colon  (3  others  enumerated  with  perforations)         3 
"      diseases  of  caecum  or  appendix  (9  others  previously  mentioned)         3 

261 


504  ON    PERITONITIS. 

"We  now  turn  to  the  second  division,  namely  peritonitis  connected 
with  a  changed  condition  of  blood,  such  as  exists  in  albuminuria,  in 
pyaemia,  in  puerperal  peritonitis,  and  in  erysipelas,  &c. 

In  albuminuria,  where  the  renal  disease  is  of  an  acute  kind,  lymph 
may  be  effused,  and  the  symptoms  of  peritonitis  are  often  well  marked  ; 
but  in  some  cases,  in  which  there  is  small  granular  kidney,  with  con- 
tracted liver,  the  peritoneum  is  thickened,  and  more  chronic  disease 
is  found  to  exist.  Albuminuria  is  a  frequent  cause  of  serous  inflam- 
mation affecting  the  pleura,  the  pericardium,  the  arachnoid,  sometimes 
the  joints,  and,  as  these  cases  show,  the  peritoneum  also.  It  rarely, 
however,  happens  that  the  peritoneum  only  is  affected,  although  such 
is  sometimes  the  case.  The  symptoms  also  are  often  masked  by  the 
distress  arising  from  the  general  anasarca,  and  the  dyspnoea  from 
cedernatous  lungs. 

Puerperal  peritonitis  is  often  associated  with  suppuration  either 
in  the  uterine  veins,  or  in  the  pelvic  cellular  tissue,  or  in  the  broad 
ligaments.  But  there  are  sometimes  instances  in  which  the  peritoni- 
tis arises  from  a  general  cause,  and  these  may  perhaps  be  considered 
as  pyaemic  or  even  of  a  rheumatic  character,  or  connected,  as  we  have 
before  said,  with  renal  disease.  Thus,  peritonitis  is  found  with  peri- 
carditis and  with  pleurisy;  with  pneumonia  and  dysentery,  or  with 
these  conditions  renal  disease  may  be  also  combined.  The  two  fol- 
lowing cases  are  worthy  of  record  in  their  causative  relation. 

CASE  CLXXXIV.  Hypertrophy  of  the  Heart.  Adherent  Pericardium. 
Acute  Pericarditis.  Pleurisy  and  Peritonitis  --  James  M  —  ,  set  9,  was  a 
delicate  boy,  who  had  suffered  from  cough,  but  there  was  no  history  of 
rheumatism  ;  he  had  been  in  the  hospital  for  disease  of  the  bones  of  the  foot, 
and  left  nearly  well  ;  in  one  week  he  returned  very  ill,  and  was  found  to  be 
suffering  from  pericarditis  ;  there  was  slight  pain  in  the  shoulder,  but  no 
swelling  of  the  joints  generally.  He  died  in  three  days.  There  was  a  ciea- 
trix  on  the  foot,  showing  the  part  from  which  the  fourth  metatarsal  bone  had 
been  removed  ;  but  there  was  no  suppuration.  There  was  general  pleurisy 
on  both  sides,  recent  lymph  in  small  quantities  being  found  ;  the  lungs  were 
congested,  and  the  bronchi  full  of  tenacious  mucus.  There  was  acute  and 
chronic  pericarditis,  as  shown  by  adhesions  of  recent  lymph,  and  in  some 
parts  by  very  firm  fibrinous  bands.  Minute  depositions  were  found  on  the 
cardiac  valves.  In  the  abdomen,  although  the  serous  membrane  had  not  lost 
its  transparency,  there  were  some  flakes  of  recent  lymph  and  a  small  quantity 
of  serum. 


Was  this  general  disease  of  the  character  of  rheumatism  ? 
must  regard  it  as  arising  from  some  general  cause,  and  in  that  re- 
spect very  different  from  so-called  idiopathic  peritonitis. 

CASE  CLXXXV.  Acute  Peritonitis.  Pericarditis.  Plenro-pneumonia. 
Small  Granular  Kidneys  —  William  B  —  ,  aet.  42,  was  admitted  into  Guy's 
Hospital,  June  13th,  1855;  he  had  been  a  laborer,  and  had  resided  in  the 
Borough.  A  year  previously  he  had  had  jaundice,  and  three  days  before 
admission  had  had  rigors,  but  on  the  following  day,  although  feeling  ill,  lie 
went  to  his  employment;  the  next  day  he  gave  up  work.  On  admission,  he 
was  very  ill,  presenting  the  signs  of  pneumonia  of  the  right  lung;  the  dulness 
rapidly  increased,  with  bronchophony  ;  much  blood  was  expectorated,  and  he 


ON    PERITONITIS.  505 

became  delirious,  but  whilst  sensible  did  riot  complain  of  pain.  The  urine 
was  not  albuminous.  He  died  on  the  20th.  There  was  recent  consolidation 
of  the  whole  of  the  right  lung ;  the  pericardium  was  covered  with  a  layer  of 
fresh  lymph  ;  there  was  also  acute  peritonitis,  the  intestines  being  adherent 
by  recent  lymph.  There  was  a  hydatid  cyst  in  the  liver,  surrounded  by  a 
dense  white  envelope,  one-eighth  of  an  inch  in  thickness,  and  containing  dis- 
integrated membrane  with  opaque  fluid  ;  the  gland  itself  was  fatty. 

The  kidneys  were  granular  and  coarse,  the  tunic  adherent,  the  secreting 
tubes  filled  with  inflammatory  products. 

The  third  and  last  class  comprises  peritonitis  of  a  general  char- 
acter, arising  from  tubercles  and  cancer,  in  which  the  peritoneal 
disease  is  often  very  insidious.  We  include  in  this  division  those 
cases  in  which,  after  a  prolonged  state  of  hyperaemia,  the  serous 
membrane  becomes  thickened,  and  a  very  slight  cause  suffices  to 
produce  acute  disease. 

The  only  remaining  causes  are  those  in  connection  with  chronic 
disease  of  the  liver  and  the  thoracic  viscera,  producing  prolonged 
hyperaemia  of  the  peritoneal  vessels  and  ascites,  and  readily  termi- 
nating in  acute  peritonitis ;  hence  the  danger  of  tapping  in  these 
instances  ;  but  acute  peritonitis  often  occurs  in  cirrhosis  from  other 
very  slight  exciting  causes. 

In  cirrhosis  the  peritoneal  covering  of  the  liver  is  very  generally 
thickened.  We  do  not,  however,  refer  to  this  merely  partial  affec- 
tion, but  to  those  in  which  the  whole  serous  membrane  is  affected. 

In  'the  second  and  third  divisions  of  cases  of  peritonitis,  the  causes 
were  as  follows  : — • 

From  Bright's  disease       .         .         .         .63 
"     pyaemia,  13  ;  erysipelas,  5  ;  puerperal 

fever,  10  ;  with  pneumonia,  3  .  31 
"  tubercular  disease  .  .  .  .70 
"  cancerous  disease  .  .  .  .40 
"  hepatic  disease  .  .  .  .27 
"  heart  disease  .....  9 


240  out  of  501  instances. 

Treatment. — The  consideration  of  the  origin  of  peritonitis,  either 
in  its  local  or  general  source,  is  the  best  guide  to  proper  treatment, 
whether  it  arise  —  1st,  from  extension  of  disease  from  adjoining 
viscera,  or  from  perforation  and  injuries;  2d,  from  blood  changes, 
such  as  occur  in  albuminuria,  pyaemia,  and  erysipelas,  &c. ;  3d,  from 
almost  imperceptible  changes  or  deficiencies  in  general  nutrition 
modifying  the  state  of  the  general  health,  as  in  struma,  cancer,  and 
climacteric  changes ;  or  from  the  hyperaemia  of  the  peritoneum,  con- 
sequent on  cirrhosis  and  chronic  disease  of  the  heart  and  lungs,  when 
upon  very  slight  exciting  causes,  acute  mischief  follows.  In  the 
first  forin^  if  perforation  have  taken  place,  perfect  rest  is  exceedingly 
important,  in  diminishing  extravasation,  and  in  localizing  the  perito- 
neal mischief;  purgative  medicines  of  all  kinds  should  be  avoided, 
and  also  stimulants,  which  are  often  unfortunately  given  at  once, 
before  a  medical  practitioner  sees  the  patient.  This  injudicious 


506  ON    PERITONITIS. 

attempt  to 'relieve  pain  by  purgatives,  carminatives,  and  stimulants, 
may  deprive  the  patient  of  the  hope  of  recovery ;  for,  as  we  have 
before  said,  we  have  seen  castor  oil  floating  in  the  peritoneal  cavity. 
Food,  also,  should  be  abstained  from,  or  only  a  few  spoonfuls  ad- 
ministered to  relieve  thirst ;  in  more  chronic  forms,  not  arising  from 
perforation,  food  of  a  fluid  and  bland  kind  only  is  admissible ;  and 
even  when  the  more  active  symptoms  have  subsided,  the  return  to 
solid  forms  of  aliment  must  be  very  cautiously  made.  When  there 
are  symptoms  of  failing  power,  stimulants  in  small  quantities  may 
be  given,  but  they  are  best  combined  with  demulcent  food,  as  brandy 
with  arrow-root,  &c. 

As  regards  medicinal  treatment,  we  believe  the  plan  recommended 
by  Dr.  Stokes  and  Dr.  Graves  to  be  of  the  greatest  value,  not  only 
in  cases  of  perforation  of  the  intestine,  but  where  the  peritoneum  is 
acutely  inflamed  from  the  direct  extension  of  disease.  It  consists  in 
the  administration  of  opium  in  full  and  repeated  doses ;  and  its  bene- 
ficial result  arises  from  its  favoring  rest  of  the  intestines  and  the 
localization  of  the  mischief,  from  the  mitigation  of  suffering  which  it 
affords,  whilst  at  the  same  time  it  alleviates  nervous  prostration  and 
collapse,  and  facilitates  reparative  action.  The  opiate  plan  may  be 
combined  with  the  external  application  of  anodyne  remedies,  such  as 
chloroform  liniment  with  belladonna  liniment,  warm  linseed  poultices, 
cotton  wool  sprinkled  with  laudanum.  Turpentine  may  be  also  ap- 
plied on  a  flannel  wrung  out  of  hot  water.  Local  peritonitis  is  also 
greatly  relieved  by  the  same  remedies  and  external  applications,  as 
when  produced  by  ovarian  and  csecal  disease;  but  blisters  are  of  value 
in  more  chronic  cases,  and  especially  in  those  instances  in  which  re- 
peated attacks  of  peritonitis  occur.  Mercury,  either  in  the  form  of 
gray  powder,  calomel,  blue  pill,  or  as  mercurial  inunction,  is,  we  be- 
lieve, injurious  in  all  these  cases  of  acute  direct  peritonitis.  It  tends 
to  prevent  adhesion,  it  excites  peristaltic  action,  it  promotes  ulcera- 
tion,  it  increases  the  depression  consequent  on  the  disease,  which  is 
often  the  immediate  cause  of  death,  and  lastly,  it  renders  the  intes- 
tinal contents  more  fluid,  thereby  increasing  extravasation.  We  are 
well  aware  that  many  instances  of  acute  peritonitis  from  diseased 
caecum,  from  enteritis,  and  from  ovarian  disease,  recover  after  mer- 
cury has  been  given;  but  as  far  as  the  causes  we  have  enumerated 
can  be  any  guide,  and  from  extensive  experience  in  these  cases,  we 
strongly  deprecate  its  use. 

Effervescent  medicines  generally  increase  the  painful  distension  of 
the  abdomen,  but  diaphoretics  and  salines  are  sometimes  of  value 
when  combined  with  opium. 

In  the  subsequent  treatment  we  must  not  be  too  desirous  of  induc- 
ing action  from  the  bowels,  and,  when  necessarv,  gentle  enemata  are 
better  than  purgatives  administered  by  the  mouth;  many  days  may 
elapse  without  any  action,  and  aperients  frequently  produce  a  renewal 
of  pain. 

When  the  more  active  symptoms  have  subsided,  opium  may  be 
continued  with  vegetable  tonics  or  with  quinine.  If  fluid  effusions 
have  formed,  iodide  of  potassium  and  diuretics  may  be  advisable, 
and  the  abdominal  glands  may  then  be  beneficially  stimulated  by  an 


ON    PERITONITIS.  507 

occasional  dose  of  gray  powder  or  calomel.  Preparations  of  iron  are 
not  generally  well  borne  in  the  convalescence  from  acute  peritonitis 
t  will  often  be  found  that  as  the  health  becomes  established  the 
fluid  effusion  rapidly  disappears ;  in  other  cases  the  repeated  applica- 
tion of  counter  irritants  may  be  required,  and  sometimes  it  is  well  to 
remove  the  serum  by  paracentesis. 

In  the  peritonitis  of  albuminuria  the  best  treatment  consists  in  the 
relief  of  the  general  disease  by  diaphoretic  medicines,  counter  irrita- 
tion and  cupping  on  the  loins,  also  bv  free  evacuation  of  the  bowels ; 
but  mercurial  preparations  very  readily  affect  the  system,  producing 
severe  salivation,  without  corresponding  benefit.  When  effusion 
becomes  extreme,  it  is  better  to  attempt  its  removal  by  puncturing 
the  thighs  and  by  purgatives  rather  than  by  directly  emptying  the 
serous  cavity.  I  have  sometimes  used  with  benefit  the  minute  drain- 
age-tubes recommended  by  Dr.  Southey.  Hot-air  baths  are  some- 
times of  great  service. 

In  the  treatment  of  the  peritonitis  of  pyaemia  and  erysipelas  the 
local  disease  is  to  be  less  regarded  than  the  general  one,  nor  should 
we  attempt  to  cure  the  peritonitis  of  this  kind  by  depletion  and  mer- 
curial preparations.  Opium  and  salines,  with  the  free  use  of  stimu- 
lants, are  apparently  the  best  remedial  agents  we  can  employ.  Ty- 
phoid symptoms  too  frequently  come  on,  and  precede  a  fatal  result. 

In  puerperal  peritonitis  the  same  plan  of  treatment  may  be  adopted. 
In  some  cases  the  blood  becomes  affected  by  the  absorption  of  septic 
material ;  or  pelvic  phlebitis  and  cellulitis  are  followed  by  the  peri- 
toneal disease ;  and,  from  the  beneficial  effect  following  the  internal 
administration  of  tincture  of  the  sesquichloride  of  iron°in  erysipelas 
and  diphtheritic  disease  of  the  throat,  Dr.  Heslop  has  recommended 
the  same  remedy  in  puerperal  peritonitis,  as  being  a  disease  closely 
allied  in  character.  Those  cases  which  we  have  seen  recover  have 
apparently  been  benefited  by  thoroughly  washing  away  uterine  dis- 
charges, by  the  free  use  of  opium,  and\y  stimulants;  but  we  are 
quite  prepared  to  hear  further  reports  of  the  good  results  of  the 
tincture  of  the  sesquichloride.  In  puerperal  peritonitis  the  use  of 
turpentine  internally  has  been  recommended,  and  has  been  followed 
sometimes  by  a  beneficial  result. 

In  the  treatment  of  acute  peritonitis  in  struma,  the  same  rules 
ought  to  be  borne  in  mind  as  in  the  treatment  of  strumous  pneu- 
monia. Opium  is  of  value  not  only  in  relieving  the  pain  and  the 
great  nervous  prostration  so  constant  in  disease  of  the  abdomen,  but 
it  also  facilitates  the  recovery  of  the  injured  structure.  Warmth 
and  anodyne  applications  may  be  used  ;  purgatives  should  be  avoided, 
and  rest  strictly  maintained  ;  but  mercurial  preparations,  given  so  as 
to  affect  the  mouth,  are  as  injurious  in  this  form  of  strumous  com- 
plication as  in  any  other,  and  it  is  not  necessary  to  recur  to  mercury 
for  an  aperient  remedy,  nor  to  prevent  the  opiates  from  checking 
secretion. 

In  the  more  chronic  forms  the  means  best  calculated  to  remove 
the  local  malady  are  those  suited  for  the  removal  of  that  general 
state  of  the  system  which  has  predisposed  to  the  complaint;  such  as 


508  ON    PERITONITIS. 

nourishment  as  far  as  it  can  be  borne,  cod-liver  oil,  steel  as  in  the 
form  of  iodide  steel  wine,  the  iodide  of  potassium,  alkalies,  &c.  Oc- 
rasionally  counter  irritants  may  be  used,  and  moderate  pressure  on 
the  abdomen  employed  to  promote  the  absorption  of  serous  effusions; 
an  elastic  bandage,  strips  of  plaster,  as  the  adhesive  or  the  belladonna 
plaster,  may  be  thus  applied;  in  some  instances  in  which  I  have 
used  the  arnmoniacum  plaster  with  mercury,  the  intolerable  itching 
which  was  produced  compelled  the  removal  of  the  application. 
Residence  at  the  seaside  greatly  facilitates- recovery  in  these  cases. 
In  slow  strumous  effusion,  especially  in  young  persons,  after  perito- 
nitis, it  is  often  extremely  difficult  to  produce  absorption,  and  para- 
centesis  is  sometimes  advisable. 

Peritonitis  with  cancerous  disease  is  always  associated  with  enfeebled 
power  and  diminished  functional  activity.  Remedies  such  as  diuretics 
have  very  little  effect  in  promoting  the  absorption  of  fluid,  and  any 
measures  which  still  further  diminish  strength  appear  to  increase 
dropsical  effusion.  To  sustain  the  powers  of  life  by  every  available 
means  is  the  best  preventive  against  this  result.  If  acute  symptoms 
supervene,  the  opiate  plan  of  treatment  must  be  followed,  with  rest 
and  bland  nutritious  diet.  If  paracentesis  be  performed,  temporary 
relief  may  be  obtained ;  but  more  frequently  the  patient  very  rapidly 
declines,  and  we  then  h'nd  that  the  whole  of  the  diseased  peritoneal 
surface  has  increased  in  vascularity  and  lymph  is  poured  out. 

Peritonitis  with  cirrhosis  is  generally  found  in  persons  who  have 
been  of  intemperate  habits;  the  arteries  are  often  diseased,  and  the 
kidneys  may  be  granular  and  atrophied.  At  an  early  stage  of  the 
disease,  when  the  diet  can  be  regulated,  and  the  excretory  functions 
of  the  liver,  the  kidneys  and  the  skin  stimulated  to  increased  action, 
the  symptoms  may,  in  a  great  degree,  be  alleviated;  and  when  acute 
peritonitis  is  set  up  with  cirrhosis,  no  class  of  cases  are  more  bene- 
fited by  the  judicious  use  of  the  ordinary  remedies  for  peritonitis, 
namely,  local  depletion,  and  mercurials  with  opium,  on  account  of 
the  stimulant  effect  which  mercurials  have  on  the  excretory  glands; 
but  all  the  good  effect  of  mercury  may  be  attained  without  that 
remedy  being  used  so  as  to  produce  salivation. 

If  the  peritonitis  be  of  a  chronic  form,  and  associated  with  ad- 
venced  cirrhosis,  our  measures  will,  at  best,  be  only  palliative.  Some 
have  recommended  mild  mercurial  salivation  before  tapping,  to 
prevent  the  supervention  of  acute  symptoms;  but  we  have  no  ex- 
perience of  such  a  treatment,  and  we  believe  that  if  tapping  be 
really  necessary  mercurial  salivation  would  be  detrimental,  and 
would  increase  the  exhaustion  which  often  follows  the  operation,  or 
that  the  mercurial  cachexia  would  lead  to  the  speedy  reaccumulation 
of  the  fluid.  Mercurial  frictions  are  less  objectionable  when  used 
with  moderation ;  and  minute  doses  of  blue  pill,  with  tonics,  as  qui- 
nine, or  with  aperients,  are,  in  many  instances  of  chronic  peritonitis 
from  hepatic  disease,  of  great  service.  Other  remedies  may  also  be 
tried,  as  diuretics,  iodide  of  potassium,  riitro-hydrochloric  acid,  &c., 
but  the  persistent  congestion  of  the  vena  portae  interferes  with  their 
absorption  and  with  their  beneficial  action.  Nearly  the  same  re- 


ON    PERITONITIS.  509 

marks  apply  to  the  treatment  of  peritonitis  coming  on  in  the  course 
of  chronic  disease  of  the  heart  and  of  the  lungs.  In  these  cases  I 
never  recommend  paracentesis,  unless  compelled  by  the  urgent 
distress  from  enormous  distension. 

We  believe  that  the  benefit  generally  ascribed  to  mercury  in  the 
treatment  of  acute  peritonitis  is  not  an  established  fact,  and  the 
good  results  which  apparently  follow  its  Tise  may,  perhaps,  be  more 
correctly  attributed  to  the  opium  with  which  it  is  usually  combined. 

M.  Beau  has  employed  large  doses  of  quinine  in  the  treatment 
of  acute  peritonitis,  but  we  have  no  experience  of  this  mode  of  treat- 
ment. 

Numerous  instances  might  be  adduced  to  illustrate  the  symptoms, 
the  pathological  appearances,  and  the  treatment  of  acute  as  well  as 
chronic  peritonitis ;  the  fearful  suddenness,  and  oftentimes  fatal  re- 
sult of  the  former,  and  the  insidious  character  of  the  latter,  might 
be  abundantly  demonstrated ;  each  chapter  has  contained  some 
illustrations  of  peritoneal  disease,  but  a  few  cases  in  which  some 
peculiarities  were  observed,  are  all  that  we  shall  mention. 

CASE  CLXXXVI.  Peritonitis.  Local  Suppuration.  Perforation  of 
the  Diaphragm — Robert  P — ,  aet.  26,  was  admitted  into  Guy's  Hospital, 
January  6th,  1858  ;  he  had  been  a  laboring  man,  residing  in  Bermondsey ; 
and  stated  that  he  had  been  well  till  seven  weeks  previously,  when  one  night 
he  was  suddenly  seized  with  violent  pain  in  the  abdomen,  accompanied  by 
vomiting  and  purging ;  he  was,  however,  able  to  walk  to  an  apothecary's 
house  the  next  day,  but  the  symptoms  remained,  and  afterwards  increased  in 
severity.  When  admitted  he  was  exceedingly  ill,  and  there  was  much  ob- 
scurity as  to  the  precise  character  of  the  disease ;  he  had  the  appearance  of  a 
patient  in  the  later  stage  of  typhoid  fever ;  the  diagnosis  was  peritoneal  dis- 
ease. He  died  on  the  9th. 

The  body  was  wasted,  the  abdomen  tumid.  The  brain  was  not  examined. 
The  left  lung  was  pushed  up,  and  its  base  was  adherent  to  the  diaphragm  ; 
when  the  lung  was  removed  its  lower  surface  was  found  to  form  part  of  an 
abscess  situated  in  the  abdomen,  and  which  had  perforated  the  diaphragm. 
The  abscess  was  in  the  left  hypochondriac  region  ;  and  the  surface  of  the 
spleen,  the  left  lobe  of  the  liver,  and  the  diaphragm  formed  its  walls ;  the 
surface  of  the  lung  opposed  to  the  opening  of  the  diaphragm  was  also  involved. 
The  fluid  in  the  abscess  was  well-formed  pus,  without  odor.  The  neighbor- 
ing organs  were  carefully  examined,  to  see  if  any  disease  in  them  had  pro- 
duced the  abscess,  but  nothing  could  be  satisfactorily  found.  The  stomach 
and  its  mucous  membrane  were  healthy.  The  duodenum  and  colon  were 
firmly  united,  and  gave  way  on  attempting  to  separate  them.  All  the  in- 
testines were  more  or  less  united,  but  there  was  no  ulceration.  The  kidneys 
were  coarse ;  the  heart  and  bronchial  glands  were  healthy. 

We  believe  that  the  local  peritoneal  disease  in  this  instance  arose 
from  some  blow  which  the  patient  had  received,  for  there  was  no 
evidence  of  perforation  of  any  of  the  viscera, 

CASE  CLXXXVI  I.  Chronic  Painless  Peritonitis.  Tubercle.  Great 

Tympanitis William  F — ,  aet.  46,  was  admitted  into  Guy's,  February  13th, 

1857,  and  died  March  26th,  1857. 

He  had  been  for  several  years  a  policeman  in  the  Borough,  and  was  of 


510  ON    PERITONITIS. 

temperate,  steady  habits.  He  had  not  received  any  blow  on  the  abdomen, 
nor  was  he  aware  of  any  exciting  cause  of  the  disease  ;  lie  had  had  diarrhoea, 
however,  some  months  previously.  Two  weeks  before  admission  the  abdo- 
men became  enlarged  and  tense,  but  without  any  pain  ;  this  increase  of  size 
went  on  till  admission,  when  the  abdomen  was  distended  and  tympanitic,  but 
still  free  from  pain. 

He  was  a  tall  man,  spare,  and  emaciated,  the  eyes  glazy  and  sunken,  the 
pupils  contracted,  and  the  conjunctiva  injected,  the  pulse  very  small,  quick, 
and  compressible,  the  tongue  clean,  the  bowels  open  regularly,  the  urine 
scanty.  In  the  abdomen  slight  fulness  could  be  detected  in  the  region  of  the 
liver ;  fluctuation  was  indistinct.  The  abdomen  was  neither  hot  nor  tender 
on  pressure.  He  was  prostrate  and  sunken  in  the  bed  ;  but  he  could  take  food 
well,  and  was  quite  sensible.  At  the  apices  of  the  chest  the  respiration  was 
very  coarse,  almost  bronchial ;  the  heart  sounds  were  normal.  The  tympani- 
tis in  great  measure  subsided  about,  a  fortnight  before  death,  but  he  became 
gradually  more  prostrate  ;  still,  he  did  not  suffer  from  any  pain.  Three  days 
before  death  his  mind  wandered  considerably.  Only  eight  or  ten  weeks 
intervened  between  the  commencement  of  the  symptoms  and  the  fatal  issue. 

Inspection  about  twelve  hours  after  death.  Abdomen. — The  intestines 
were  moderately  distended  ;  the  peritoneum  contained  about  two  quarts  of 
bloody  serum ;  the  intestines  were  everywhere  covered  over  with  lymph  in 
grains  somewhat  resembling  tubercles  ;  there  were  some  tolerably  strong  bands 
of  adhesion,  and  the  small  intestines  were  united  together,  but  not  firmly. 
The  investment  of  the  spleen  was  more  than  a  quarter  of  an  inch  in  thick- 
ness, and  of  a  whitish  color  from  lymph,  and  contained  yellow  opaque  grains 
or  cheesy  masses  from  degenerating  tissue.  The  appendix  was  coiled  like  the 
letter  S,  on  the  right  side  of  the  cascum,  and  was  adherent.  The  liver  was 
fatty;  the  spleen  semi-diffluent ;  the  kidneys  somewhat  granular  and  atrophied. 
The  mesenteric  glands  were  healthy.  The  stomach  was  contracted  and  small, 
and  presented  scarcely  any  post-mortem  solution.  In  the  ileum  were  several 
small  passive  ulcers,  extending  through  the  mucous  membrane,  but  without 
any  injection  around  them.  The  caecum  and  colon  were  healthy.  The  ap- 
pendix contained  feces  surrounded  by  thickened  mucus.  Chest — The  pleura 
was  adherent  at  both  apices,  but  especially  on  the  left  side;  the  left  apex  was 
puckered,  and  was  of  an  iron-gray  color,  consolidated,  and  it  contained  some 
calcareous  masses  ;  some  small  granular  masses  resembling  tubercles  were 
observed.  At  the  base  of  the  right  lobe  were  several  lobules  consolidated, 
and  some  were  in  a  state  of  softening,  or  gray  hepatization  ;  they  were  situated 
beneath  the  pleura  as  in  pyaemia.  The  heart  was  healthy,  except  slight 
atheroma  of  the  valves.  The  tubercles  in  the  peritoneum  consisted  of  elon- 
gated fibre-cells,  with  a  nucleus  rendered  very  distinct  by  acetic  acid ;  in 
some  parts  more  rounded  nucleated  cells  were  closely  aggregated,  in  others 
fibres  were  formed  ;  some  portions  showed  degenerating  tissue.  The  structure 
was  more  highly  organized  than  in  struma,  but  it  could  not  be  considered 
cancerous. 

Many  facts  of  great  interest  were  presented  in  this  case.  1st.  The 
insidious  character  of  the  peritonitis,  unaccompanied  by  pain,  but 
marked  by  tympanitis,  with  gradually  increasing  prostration.  2d. 
The  blood  effused  into  the  serous  membrane,  which  apparently  arose 
from  the  rupture  of  newly-formed  capillaries.  3d.  The  apparent 
tendency  to  struma,  as  shown  by  the  condition  of  the  lungs,  which 
presented  a  retrocedent  state  of  chronic  pneumonia.  4th.  The  condi- 
tion of  the  blood,  as  indicated  by  the  pysemic  lobular  pneumonia, 


ON    PERITONITIS.  5J_|_ 

the  diffluent  state  of  the  spleen,  and  the  effusion  of  blood  into  the 
peritoneum      As  to  the  exciting  or  predisposing  causes  of  disease 
nothing  could  be  found ;  it  was  not  a  case  apparently  of  enteric  fever  • 
he  had  not  been  more  exposed  than  policemen  generally  are  to  cold 
r  wet ;  he  had  been  a  man  of  temperate  habits,  and  there  was  no 
isease  of  the  liver  beyond  fatty  degeneration.     The  probable  pre- 
.isposing  cause  was  the  strumous  diathesis.     We  have  already  re- 
ferred to  this  case  as  one  which  might  easily  have  been  mistaken  at 
an  early  stage  for  one  of  functional  dyspepsia;  and  other  cases  of  a 
similar  kind  have  come  under  our  notice. 

CASE  CLXXX  YIN  Ulceration  of  the  Intestine.  Strumous  Peritonitis, 
fecal  Abscess.  Umbilical  Discharge.— Mary  Ann  E— ,  jet.  38,  by  occupa- 
tion a  servant,  was  admitted,  under  Dr.  Hughes'  care,  into  Guy's  Hospital, 
Hh,  1857,  and  died  on  August  4th.  She  had  resided  at  Brixton  and 
[  two  months  previous  was  quite  well,  when  she  began  to  suffer  from  pain 
in  the  abdomen  ;  this  gradually  increased  with  vomiting  and  distension  ;  and 
at  last  several  tumors  appeared.  On  admission  she  was  very  ill,  with  symp- 
toms of  general  peritonitis,  tenderness,  distension,  &c.  Three  or  more  denned 
tumors  could  be  felt ;  one  at  the  umbilicus,  a  second  in  the  ri^ht  hypochon- 
dnum,  and  a  third  on  the  left  side.  They  could  be  reduced  by  pressure^  and 
fluctuation  was  believed  to  be  felt.  On  July  30th  the  tumor  near  the  um- 
nhcus  burst  at  that  part,  and  pus  having  a  fecal  odor  was  discharged  She 
d,ed  on  August  4th.  The  body  was  wasted.  The  thoracic  viscera  were 
Ihere  was  a  large  fecal  abscess  below  the  umbilicus  circumscribed 
by  the  liver  and  the  colon,  and  extending  into  the  transverse  colon  ;  upon 
attempting  to  separate  the  intestine,  further  openings  were  made.  Numerous 
ulcers  were  found  in  the  ileum,  cascum,  and  colon ;  and  most  of  these  ulcers 
had  perforated  the  coats  of  the  intestine  ;  extravasation  had,  however,  been 
prevented  by  adhesions.  Between  the  coils  of  intestine  close  to  the  mesen- 
tery were  several  loose  earthy  bodies,  and  similar  ones  were  found  in  the 
mesenteric  glands.  The  liver  was  fatty. 

Although  there  was  no  evidence  of  tubercular  disease  in  the  lungs 
of  this  patient,  we  regarded  the  case  as  one  of  strumous  disease  of 
the  abdomen,  from  the  condition  of  the  mesenteric  glands,  and  the 
general  character  of  the  disease.  It  is  probable  that  ulceration  of 
the  mucous  membrane  of  the  ileum  first  took  place,  possibly  from 
enteric  fever,  and  afterwards  chronic  peritonitis  supervened;  the 
latter  was  marked  by  severe  attacks  of  pain  and  vomiting ;  adhe- 
sions between  the  coils  of  the  intestine  then  formed,  and  limited  the 
extravasation  which  subsequently  took  place  from  the  perforated 
intestine. 

In  strumous  peritonitis  suppuration  sometimes  arises  from  the  de- 
generation of  the  low  organized  peritoneal  product,  and  the  pus 
forms  an  opening  into  the  intestine,  namely,  from  the  peritoneal  to 
the  mucous  surfaces.  In  other  cases,  the  perforation  is  from  within; 
the  extensive  ulceration  of  the  small  and  large  intestine  in  this  case 
rendered  it  probable  that  the  latter  was  the  course  of  the  disease. 
The  external  opening  at  the  umbilicus  is  a  rare  event  in  these  cases, 
and  if  a  fecal  abscess  thus  opening  had  been  the  only  one,  great  relief 
to  the  pain  and  distress  might  have  followed;  but  these  collections  of 


512  OX    PERITONITIS. 

fecal  matter  were  numerous.  The  calcareous  condition  of  some  of 
the  mesenteric  glands,  and  loose  calcareous  bodies  of  similar  kind  in 
their  neighborhood,  are  interesting  facts  connected  with  the  expla- 
nation of  loose  bodies  sometimes  found  in  the  serous  sac. 

CASE  CLXXXIX.  Ascites.  Cancer  of  the  Ovaries  and  Peritoneum. 
Paracentesis.  Peritonitis. — Ann  II — ,  aet.  45,  was  admitted  under  my  care 
September  20th,  1858.  She  was  a  single  woman,  and  had  ceased  to  men- 
struate in  December,  1857.  Since  that  time  the  abdomen  had  begun  to 
swell,  and  ascites  came  on ;  she  was  tapped,  and  dark  colored  fluid  was  drawn 
off;  vomiting  with  severe  pain  in  the  abdomen  supervened,  and  continued 
till  her  admission.  There  was  then  great  emaciation,  and  irritability  of  the 
stomach  was  still  very  troublesome.  The  abdomen  became  very  large,  and 
fluctuation  very  distinct.  Severe  pain,  with  tympanitis,  subsequently  came 
on,  and  she  gradually  sank. 

On  inspection,  the  peritoneum  was  found  studded  with  cancerous  tubercles; 
the  omentum  was  contracted,  and  contained  much  deposit;  the  stomach  was 
irregularly  contracted  into  two  pouches;  the  pylorus  was  healthy;  but  an 
inch  from  the  pylorus  its  coats  were  invaded  by  cancerous  disease  ;  the  mucous 
membrane  in  several  parts  was  intensely  congested.  The  intestines  were 
distended  with  flatus,  and  there  were  indications  of  peritonitis  at  the  lines  of 
contact  of  the  coils  of  the  intestine;  some  serous  effusion  was  observed.  The 
deposit  on  the  peritoneum  consisted  of  abundant  nuclei.  There  was  a  medul- 
lary tubercle  in  the  kidney;  the  glands  were  otherwise  healthy,  but  there 
were  no  tubercles  in  the  liver.  The  pleura  presented  numerous  tubercles ; 
and  there  was  a  considerable  quantity  of  serous  effusion  in  botli  serous  cavi- 
ties. The  heart  was  normal.  The  spleen  was  enlarged.  Both  ovaries  witli 
the  uterus  were  united  into  one  mass  by  deposit  of  a  fibro-medullary  char- 
acter; and  numerous  cysts  were  observed  containing  secondary  cysts.  The 
os  uteri  was  healthy. 

The  acute  peritoneal  mischief  was  set  up  by  the  paracentesis; 
constant  pain,  and  almost  daily  vomiting,  with  gradually  increasing 
exhaustion  followed,  till  death  ensued.  The  onset  of  the  disease 
was  insidious,  and  probably  arose  in  the  ovaries;  cancerous  tuber- 
cles were  then  developed  on  the  peritoneum,  and  effusion  took  place. 
This  effusion  may  be  without  pain,  excepting  that  arising  from  dis- 
tension; at  length  the  large  size  of  the  abdomen,  the  painful  disten- 
sion, the  inability  to  take  food  from  the  pressure  on  the  stomach, 
the  impeded  respiration,  the  sleepless  nights,  and  the  general  distress, 
cause  the  patient  to  long  for  relief;  but  there  is  always  the  danger 
of  more  acute  inflammatory  disease  being  set  up,  as  was  the  case  in 
this  patient  before  she  applied  for  admission  into  Guy's  Hospital. 

CASE  CXC.  Carcinoma  of  the  Peritoneum,  with  Effusion.  Paracen- 
tesis— Mary  T — ,  ret.  57,  admitted  into  Guy's  Hospital  April  25th,  1857, 
and  died  on  August  28th. 

She  stated  that  about  two  months  before  admission  the  abdomen  began  to 
swell,  and  gradually  increased.  On  June  13th,  paracentesis  abdominis  was 
performed,  and  again  on  July  Uth;  at  each  operation  more  than  five  gallons 
of  fluid  being  drawn  off.  No  signs  of  peritonitis  followed,  but  she  gradually 
sank. 

On  inspection,  the  lungs  and  pleura  were  found  to  be  healthy ;  there  was 
recent  lymph  effused  on  the  anterior  aspect  of  the  pericardium,  upon  the 


ON    PERITONITIS. 

ventricles;  and  a  small  quantity  posteriorly.  In  the  abdomen  there  were 
several  pints  of  fluid;  numerous  white  cancerous  nodules  were  scattered  over 
the  serous  membrane,  especially  on  the  intestines.  The  membrane  also  was 
thickened  by  chronic  action,  in  a  more  marked  degree  on  the  anterior  parie- 
The  peritoneum  covering  the  liver  was  opaque,  and  in  some  places 
tubercular.  The  omentum  was  drawn  up  and  formed  a  solid  mass  (cancerous) 
The  lymphatic  glands  were  only  slightly  affected,  but  there  were  some  large 
masses  between  the  diaphragm  and  the  liver.  The  surface  of  the  diaphrao-m 
itself  was  affected;  the  tunic  of  the  spleen  was  opaque;  the  liver,  spleen 
suprarenal  capsules  and  kidney  were  healthy.  The  right  ovary  consisted  of 
a  mass  of  new  growths  and  cysts,  about  the  size  of  the  fist;  the  former  were 
made  up  of  a  spongy-looking  fungus,  composed  of  fibre-cellular  structure,  and 
the  latter  were  filled  with  fluid.  There  were  some  smooth  cavities  containing 
a  soft  sebaceous  matter,  and  amongst  this  were  numerous  hairs. 

In  this  case  the  disease  also  probably  commenced  in  the  ovaries- 
there  was  absence  of  pain,  but  gradual  effusion;  the  ascites  was,' 
however,  greatly  relieved  by  paracentesis,  no  acute  peritonitis  fol- 
lowed, but,  as  too  frequently  happens,  the  fluid  soon  re-collected 
and  again  required  to  be  drawn  off;  but  at  each  time  the  patient 
was  less  able  to  rally  from  the  effect  of  the  operation. 

CASE  CXCI.  Chronic  Peritonitis.  Renal  Disease.  Spurious  Cysts  in 
the  Peritoneum — Elizabeth  S— ,  set.  44,  a  stout  married  woman,  was  admitted 
December  7,  1859,  under  Dr.  Barlow's  care,  and  died  February  11,  1860. 
She  had  been  confined  eight  months  before  admission;  and  swelling  of  the 
legs  was  followed  by  effusion  into  the  abdomen.  There  was  general  anasarca, 
and  the  urine  was  albuminous.  The  abdomen  became  distended ;  there  was 
distressing  cough  ;  prostration  supervened,  and  she  gradually  sank. 

Inspection — There  was  effusion  into  the  left  pleura,  and  the  bronchial  tubes 
were  much  congested.  Heart — The  muscular  fibre  was  pale  ;  the  right  and 
left  ventricles  were  both  much  dilated.  Abdomen The  intestines  were  dis- 
tended ;  on  opening  the  serous  membrane  an  appearance  very  closely  resem- 
bling ovarian  dropsy  presented  itself.  The  supposed  cyst  on  the  right  side 
consisted  of  peritoneal  effusion,  shut  off  by  fibrinous  adhesions.  This  serous 
collection  extended  from  the  right  iliac  region  as  high  as  the  liver,  and  be- 
tween the  liver  and  diaphragm  ;  the  fibrous  cyst  could  in  great  measure  be 
separated  from  the  peritoneum,  and  contained  many  pints  of  slightly  milky 
serum.  Another  cyst  was  found  between  the  colon  and  the  stomach.  The 
mesentery  was  slightly  contracted,  and  all  the  intestines  were  matted  together. 
The  kidneys  contained  cysts  and  some  inflammatory  deposit.  The  liver  was 
soft  and  congested.  The  ovaries  were  atrophied. 

Effusion  into  the  peritoneum  with  serous  inflammation  is  of  fre- 
quent occurrence  in  renal  disease,  and  such  was  the  cause  of  the  as- 
cites in  this  case.  It  is,  however,  especially  recorded  on  account  of 
the  very  peculiar  appearance  that  was  presented  on  opening  the  ab- 
domen ;  there  was  the  precise  resemblance  of  a  patient  affected  with 
ovarian  dropsy,  for  the  lymph  effused  upon  the  peritoneum  had 
formed  a  cyst,  and  shut  off  the  serous  exudation.  The  lymph  with 
its  contained  serum  could  be  separated  from  the  liver  and  intestine, 
but  the  ovaries  themselves  were  healthy. 

OO 


514  ON    PERITONITIS. 

CASE  CXCII.  Colloid  Cancer  of  the  Peritoneum  and  Ascending  Colon — 
Harriet  K — ,  aet.  32,  a  hawker  residing  in  Kent  Street,  was  admitted  into 
Guy's  Hospital  March  27th,  1861,  under  the  care  of  Dr.  Rees.  Her  general 
health  was  good,  and  her  habits  of  life  temperate ;  but  she  had  an  aniumic 
appearance.  Her  employment  exposed  her  to  wet,  cold,  and  fatigue,  and 
she  had  evidently  suffered  from  causes  of  depression,  having  had  improper 
food,  and  the  care  of  a  family  of  five  children.  There  was  no  history  of 
hereditary  disease. 

Six  months  previous  to  her  admission  she  was  seized  with  a  sharp  pain  at 
the  lower  part  of  the  abdomen,  and  the  pain  was  increased  on  pressure.  From 
that  time  the  bowels  became  relaxed,  but  the  diarrhoea  had  been  more  severe 
for  three  months,  ten  to  twelve  motions  being  passed  ;  the  motions  were  of  a 
dark  color,  and  sometimes  were  of  a  white  glairy  matter,  like  white  of  egg. 
Small  masses  of  indurated  feces  were  also  sometimes  passed.  She  complained 
of  a  sense  as  of  great  weight  at  the  lower  part  of  the  abdomen  when  standing. 
For  a  short  time  she  suffered  from  dyspnoea,  but  the  cough  was  slight ;  the 
expectoration  was  greenish  and  tenacious.  There  had  been  no  catamenial 
discharge  for  eighteen  months.  She  suffered  from  vomiting;  the  pulse,  120, 
was  small  and  soft ;  the  tongue  was  dry  in  the  centre,  but  the  tip  and  edges 
were  clean  and  moist.  The  diarrhoea  continued  to  the  close,  but  it  was  par- 
tially checked  by  treatment ;  she  sank  a  week  after  admission. 

Inspection  was  made  twenty-four  hours  after  death.  The  thoracic  viscera 
were  natural.  The  whole  of  the  peritoneum  was  covered  with  colloid  cancer, 
which  extended  from  the  diaphragm  to  the  pelvis  :  no  viscera,  however,  were 
involved  except  the  ascending  colon,  and  it  was  doubtful  whether  this  was 
primary  or  secondary  disease.  On  opening  the  abdomen  the  omentum  was 
seen  spread  over  the  surface  of  the  intestine,  and  reached  nearly  to  the  pubes. 
The  mesentery  was  converted  into  a  solid  mass  of  colloid,  an  inch  in  thick- 
ness, and  of  considerable  density.  It  formed  a  tolerably  uniform  mass,  except 
at  the  edges,  where  the  disease  existed  in  the  form  of  distinct  nodules ;  the 
omentum  was  slightly  adherent.  On  raising  the  omentum  adhesions  existed 
with  the  ascending  colon,  and  on  opening  this  portion  of  the  intestine  the 
walls  were  found  to  be  involved,  and  in  part  destroyed  by  the  disease.  The 
cascum  itself  was  free,  but  above  it  the  walls  of  the  colon  were  converted  into 
a  solid  tumor  for  about  five  inches.  In  other  parts  the  disease  was  confined 
to  the  peritoneum,  but  in  the  ascending  colon  it  had  penetrated  the  coats  and 
had  partially  destroyed  them  ;  thus,  on  section,  the  muscular  coat  could  be 
seen  traversing  the  centre  of  the  colloid  growth.  The  mesentery  and  its 
glands  and  the  lumbar  glands  were  free  from  disease ;  but  the  whole  of  the 
diaphragmatic  peritoneum  was  covered,  so  also  the  peritoneal  surface  of  the 
bladder,  liver,  and  spleen.  The  substance  of  the  liver  and  spleen  were 
healthy,  so  also  the  kidneys,  uterus,  and  ovaries.  The  left  iliac  vein  was 
distended  with  an  ante-mortem  clot.  The  microscope  showed  colloid  struc- 
ture in  the  peritoneal  growth. 

This  was  a  well-marked  instance  of  colloid  disease  of  the  perito- 
neum originating  in  similar  disease  of  the  colon.  A  glairy  discharge 
from  the  bowels  was  present,  but  I  have  not  observed  this  symptom 
in  other  instances  of  colloid  disease  which  have  come  under  my 
notice.  Pain  in  the  region  of  the  colon  was  the  first  indication  of 
disease,  and  was  followed  by  diarrhoea  of  a  very  persistent  character, 
by  vomiting,  and  gradual  prostration.  There  was  nothing,  however, 
during  the  course  of  the  complaint  to  enable  us  to  diagnose  its  pre- 


ON    PERITONITIS.  515 

cise  character.     The  patient  was  only  thirty-two  years  of  age,  but 
she  had  had  five  children. 

LOOSE  BODIES  are  occasionally  found  in  the  peritoneal  cavity,  oval 
in  form,  and  in  size  varying  from  that  of  a  bean  to  that  of  a  pigeon's 
egg.  They  do  not  appear  to  produce  any  symptom,  but  they  have 
been  known  to  pass  into  hernial  sacs.  They  are  variously  constituted. 
1st.  Some  arise  from  growths  connected  with  the  intestine,  and  whilst 
some  may  be  quite  free,  others  are  found  pendant  by  long  thread- 
like bands.  2d.  The  separation  of  appendices  epiploicse  apparently 
constitutes  others,  as  in  a  case  recorded  by  Mr.  Shaw,  and  as  shown 
by  the  arrangement  of  its  layers.  3d.  The  separation  of  calcareous 
and  degenerate  glands  may  also  give  rise  to  these  loose  bodies.  This 
mode  of  formation  appeared  probable  in  Case  CLXXXVIII.  4th. 
The  coagulation  of  fibrinous  masses  or  of  blood  may  lead  to  their 
.formation  ;  but  this  source  is  of  very  doubtful  occurrence,  although 
in  spurious  melanosis  dark  portions  of  effused  blood  may  seem  to  be 
in  an  almost  separated  condition.  5th.  Other  occasional  but  rare 
conditions  are  proliferous  cysts,  simple  and  dermoid  cysts. 


516 


CHAPTER   XX. 

ASCITES.         DROPSY. 

THE  term  dropsy  is  often  limited  in  its  application  to  the  effusion 
of  fluid  into  the  peritoneal  cavity;  this,  however,  is  more  correctly 
designated  ascites,  or  peritoneal  dropsy.  The  peritoneum  is  the  lin- 
ing membrane  of  the  cavity  in  which  the  intestines  and  numerous 
other  viscera  are  placed,  it  is  a  serous  membrane  like  the  pleura,  and 
covered  over  by  a  cellular  investment,  formerly  regarded  as  epithelial: 
modern  histologists  have  shown  that  this  is  not  strictly  true,  for  the 
peritoneal  cells  are  part  of  the  connective  tissue,  and  therefore  endo- 
thelial.  The  serous  membrane  is  richly  supplied  with  vessels,  and 
it  is  from  these  when  in  a  state  of  active  or  passive  congestion  that 
the  effusion  takes  place  ;  these  vessels  participate  in  the  more  acute 
changes  of  peritonitis,  in  which  lymph  and  fibro-albumiuous  pro- 
ducts, and  the  various  manifestations  of  cellular  growth  are  found. 
The  membrane  has  also  abundant  lymphatic  vessels.  It  is,  however, 
especially  with  fluid  effusions  into  the  serous  membrane  that  we  have 
now  to  do.  These  fluids  are  variously  composed,  according  to  the 
nature  of  the  process  which  has  led  to  them;  the  quantity  of  albumen 
varies,  and  sometimes  leucocytes  and  cells  are  found  answering  to  true 
pus  cells;  blood  is  sometimes  present,  and  if  the  fibrinous  material  be 
abundant  it  may  be  recognized  after  death  in  a  coagulated  form  ;  some- 
times urea  is  present,  and  generally  some  saline  constituents.  The 
quantity  of  the  fluid  is  equally  variable  ;  it  may  be  only  a  few  ounces 
which  gravitate  into  the  pelvis,  or  it  may  amount  to  several  gallons. 
The  fluid  is  usually  transparent,  of  a  greenish-yellow  color,  and  slightly 
alkaline  in  reaction.  If  there  be  disease  of  the  lymphatic  vessels, 
the  fluid  becomes  milky  and  opalescent,  so  also  it  is  turbid,  if  inflam- 
matory action  have  place,  and  proportionately  so,  as  the  fluid  is  more 
or  less  purulent.  "We  have  already  referred  to  the  occasional  pres- 
ence of  blood;  this  may  arise  from  a  transudation  of  has  ma  tine  in 
consequence  of  a  changed  character  of  the  blood,  as  in  purpura,  or 
it  may  be  due  to  rupture  of  congested  vessels,  as  in  heart  disease,  or 
even  to  the  rupture  of  newly  formed  capillaries.  Sometimes  the 
fluid  is  more  thick  and  viscid.  For  the  convenience  of  description 
as  well  as  of  diagnosis  and  of  treatment,  it  may  be  well  to  divide  as- 
cites into  several  varieties. 

1.  From  weakness,  asthenic  dropsy,  such  as  we  find  in  old  age  and 
in  states  of  exhaustion. 

2.  From  congestion  of  a  passive  character,  mechanical  or  secondary 
dro/tsy,  such  as  we  have  in  chronic  bronchitis,  in  emphysema,  in  heart 
disease,  in  pressure  on  the  vena  cava,  and  to  some  extent  in  chronic 


ASCITES.       DROPSY.  517 

disease  of  the  liver,  cirrhosis.     In  all  these  states  the  vena  portse 
and  its  tributary  branches  are  over-distended. 

3.  From  peritoneal  inflammation  and  congestion  of  an  active  kind 
inflammatory  dropsy. 

4.  From  disease  of  the  liver,  the  kidneys,  the  spleen,  and  the  lym- 
phatic glands,  glandular  dropsy. 

5.  From  strumous  or  tubercular  disease. 

6.  From  cancerous  disease  of  the  peritoneum  in  its  several  forms 
whether  primary  or  secondary. 

7.  Ovarian  dropsy.    This,  however,  is  not  ascites,  although  ascites 
may  be  associated  with  it.     The  disease  is  limited  to  the  ovaries, 
and  the  effusion  is  cystiform. 

The  first  symptom  of  the  presence  of  fluid  in  the  peritoneum  is 
the  increase  in  size  of  the  abdomen;  the  quantity  generally,  however, 
attains  to  a  considerable  proportion  before  it  is  noticed  by  the  patient. 
Then,  unless  the  patient  is  stout,  and  there  is  a  large  quantity  of  fat 
in  the  parietes  or  in  the  omentum,  the  fluid  may  be  detected  by  the 
sense  of  fluctuation  which  is  communicated  when  one  hand  is  placed 
on  one  side  of  the  abdomen  and  a  gentle  tap  is  given  on  the  opposite 
side ;  or  if  the  fluid  is  small  in  quantity  and  the  loin  is  bulging,  one 
hand  may  be  placed  towards  the  back,  and  a  gentle  blow  given  on 
the  same  side  in  front ;  the  readiness  with  which  fluctuation  can  be 
felt  is  greater  if  the  parietes  of  the  abdomen  be  thin.  The  fluid  in 
the  abdomen,  unless  it  be  limited  by  adhesion,  will  flow  from  side  to 
side  and  gravitate  according  to  the  position  of  the  patient.  It  will 
fill  the  pelvis,  and  if  the  patient  lie  upon  the  back  it  will  pass  into 
the  loins;  the  form  of  the  abdomen  is  altered,  therefore,  by  the  bulg- 
ing of  the  loins  and  the  apparent  flaccid  condition  of  those  parts. 
If,  however,  there  be  irritation  of  the  peritoneum,  as  from  inflamma- 
tory action,  or  from  the  presence  of  cancerous  tubera  upon  the  serous 
membrane,  there  is  greater  tension  of  the  muscular  walls  of  the  abdo- 
men and  less  projection  of  the  loins.  The  quantity  of  fluid  may  be 
estimated  by  the  extent  of  the  dulness  when  a  patient  is  in  a  standing 
position  as  compared  with  that  on  lying  down;  where  fluid  is  present 
immediately  beneath  the  parietes  there  is  dulness,  and  where  there 
is  intestine  there  is  resonance  on  percussion;  hence  we  find  in  ordi- 
nary cases,  if  the  effusion  be  moderate  in  quantity,  that  the  intestines 
float  on  the  fluid,  and  the  abdomen  is  resonant  in  front,  whilst  there 
is  dulness  on  the  side,  from  the  gravitation  towards  the  loins;  if, 
however,  the  patient  turn  on  one  or  other  side,  the  line  of  dulness  is 
altered,  for  the  fluid  passes  from  one  side  to  the  other.  If  the  fluid 
is  in  very  large  quantity  and  the  abdomen  is  so  distended,  that  the 
intestine  being  held  back  by  the  mesentery  cannot  reach  its  anterior 
wall,  the  dulness  is  general.  Again,  in  some  cases  of  chronic  inflam- 
mation, the  mesentery  becomes  thickened  and  contracted  and  the 
same  restraining  effect  is  produced,  because  the  intestines  are  tied 
down;  still  further,  adhesions  may  limit  the  fluid,  so  that  it  cannot 
gravitate  to  the  dependent  parts.' 

Other  symptoms  are  produced  by  ascitic  distension ;  the  skin  be- 
comes stretched,  the  coriurn  gives  way,  and  transverse  markings  are 


518  ASCITES.      DROPSY. 

produced,  they  may  be  of  a  reddish  color,  but  frequently  when  the 
distension  is  lessened  they  assume  a  white  appearance,  as  seen  after 
pregnancy  ;  in  very  great  distension,  the  umbilicus  sometimes  yields, 
it  bulges  out  in  a  globular  form;  the  skin  is  thin,  and  the  vessels  are 
evident;  sometimes  rupture  takes  place,  and  the  fluid  escapes,  a 
result  to  be  avoided  if  possible,  as  it  often  leads  to  acute  peritoneal 
inflammation  and  the  exhaustion  of  the  patient.  If  the  inguinal 
canal  is  open,  fluid  may  pass  into  the  scrotum ;  but  the  distension  of 
the  tunica  vaginalis  must  not  be  mistaken  for  swelling  of  the  scrotum 
produced  by  oedema  or  by  pressure  on  the  veins.  When  the  ascites 
is  great,  there  is  also  pressure  on  the  large  vein  of  the  abdomen,  the 
vena  cava;  then  the  blood  is  prevented  from  returning  from  the 
lower  extremities  and  oedema  is  the  result;  and  therefore,  in  ordinary 
ascites,  the  enlargement  of  the  abdomen  always  precedes  the  swelling 
of  the  feet  and  legs.  The  interference  with  the  venous  circulation 
also  alters  the  state  of  the  kidneys;  the  renal  veins  are  distended, 
the  glands  act  feebly  from  the  passive  congestion,  urine  is  often 
scanty  and  is  not  increased  by  diuretic  medicines;  but  as  soon  as  the 
pressure  is  removed  by  paracentesis  then  the  kidneys  act  freely. 
The  fluid  also  presses  upon  the  upper  part  of  the  abdomen  and  the 
diaphragm ;  the  liver  is  pushed  up  on  the  right  side,  and  the  spleen 
on  the  left;  and  the  fluid  may  pass  over  the  edge  of  the  liver,  be- 
tween it  and  the  parietes.  Digestion  is  also  interfered  with,  for  the 
stomach  is  compressed;  sometimes  severe  vomiting  is  induced  or 
there  is  loss  of  appetite,  pain  after  food,  and  sense  of  great  distension. 
It  is  very  remarkable  how  these  gastric  symptoms  may  suddenly 
cease  when  the  pressure  is  taken  off.  We  have  already  referred  to 
the  fluid  passing  into  the  pelvis,  the  bladder  and  rectum  may  both 
be  compressed,  and  in  women  the  fluid  may  be  felt  in  the  recto-vesi- 
cal  pouch.  The  general  symptoms  as  to  the  pulse,  the  tongue,  the 
temperature  and  the  respiration,  vary  according  to  the  state  of  the 
patient.  The  fluid  in  the  peritoneum  may,  however,  be  associated 
with  a  solid  tumor,  whether  in  the  ovary,  in  the  glands  or  in  other 
parts;  again  a  hydatid  cyst  in  any  of  the  abdominal  viscera  may 
complicate  the  diagnosis.  A  large  ovarian  cyst  may  be  present  and 
be  recognized  by  its  fixed  position,  the  non-gravitation  of  the  fluid 
&c.,  but  it  may  be  associated  with  ascites;  there  may  be  fluid  outside 
the  cyst  in  the  peritoneum ;  lastly,  pregnancy  may  be  present  with 
ascites.  Pregnancy  is  sometimes  attempted  to  be  hidden  under  the 
name  of  dropsy,  and  a  medical  man  ought  never  to  be  thrown  off  his 
guard  in  this  respect. 

1.  Ascites  from  weakness,  asthenia  or  exhaustion  is  sometimes 
observed  after  loss  of  blood,  or  in  chronic  disease,  as  in  the  latter 
stages  of  phthisis;  and  we  may  in  advanced  life,  when  the  circulation 
has  become  very  feeble,  observe  the  same  condition.  The  fluid  in 
these  cases  slowly  collects,  there  is  neither  pain  nor  inflammatory 
action ;  the  ankles,  and  even  the  whole  leg,  become  cedematous. 
The  effusion  is  of  a  passive  character,  and  is  due  to  the  feeble  con- 
dition of  the  circulation,  and  it  may  be,  to  obstruction  of  the  vessels 
from  thrombosis;  there  is  no  febrile  disturbance,  and  the  patient  is 


ASCITES.      DROPSY.  519 

often  unconscious  of  the  ascitic  enlargement.  In  these  instances  the 
ascites  is  purely  symptomatic  of  a  state  of  general  exhaustion  •  no 
treatment  is  required,  beyond  what  is  necessary  to  sustain  the  feeble 
circulation;  to  attempt  to  remove^  the  fluid  by  purgatives  and 
diuretics  would  lead  to  increased  weakness  and  would  also  augment 
the  ascites. 

2  Ascites  produced  by  congestion  of  the  portal  circulation.  This 
is  also  of  a  passive  character  and  is  secondary  to  other  disease,  and 
may  be  regarded  as  mechanical  as  to  the  manner  in  which  it  is'  pro- 
duced. The  hepatic  dropsy  to  which  we  have  presently  to  refer,  is, 
in  many  instances,  of  the  same  secondary  character.  The  minute 
branches  of  the  portal  vein  are  distributed  everywhere  upon  the 
abdominal  viscera,  the  stomach,  the  small  and  large  intestine  as  well 
as  upon  the  peritoneum ;  congestion  of  these  vessels,  which  is  often 
of  an  extreme  character,  leads  to  the  discharge  of  serous  fluid  into 
the  general  cavity  of  the  peritoneum.  It  commences  in  the  abdomen 
f  the  liver  only  is  affected,  but  in  the  cases  to  which  we  now  refer, 
the  obstruction  extends  to  the  cava  and  the  legs,  and  the  legs  and  feet 
also  become  oedematous.  These  cases  are  especially  those  of  obstruc- 
tive disease  of  the  valves  of  the  heart,  and  obstruction  in  the  lungs,  as 
we  find  m  chronic  bronchitis  and  emphysema.  In  the  former  class  of 
maladies,  cardiac  affection,  we  may  instance  stenosis  or  contraction  of 
the  mitral  valve  ;  the  blood  is  unable  to  pass  onwards  freely  ;  the  left 
auricle  is  first  overstretched,  next  the  pulmonary  veins,  and  thus  the 
whole  lungs  necessarily  become  surcharged ;  hence  also  the  chronic 
congestion  of  the  lungs,  the  attacks  of  pulmonary  apoplexy  and  of 
pleuritic  effusion.  Since,  however,  the  blood  is  retarded  in  the  lungs, 
the  right  side  of  the  heart  is  next  distended,  and  the  power  of  the 
right  ventricle  is  overtaxed  to  propel  the  blood  onward  ;  the  muscle 
becomes  hypertrophied  and  the  cavity  dilated ;  next  the  right  auricle 
is  similarly  distended,  and  the  blood  is  retarded  in  the  superior  cava, 
and  also  in  the  inferior  cava;  the  large  hepatic  veins  opening  into 
the  cava  immediately  before  it  passes  the  diaphragm,  to  reach  the 
auricle  of  the  heart,  necessarily  become  distended,  hence  the  con- 
gestion of  the  liver,  its  increase  in  size,  and  the  nutmeg  appearance 
it  presents.  Not  only  are  the  veins  of  the  liver  overstretched,  but 
also  those  which  form  the  inferior  cava,  the  renal  veins  and  the  iliac 
veins  from  the  pelvis  and  lower  extremities ;  it  is  in  this  way  that 
oedema  of  the  feet  is  produced  as  well  as  ascites,  the  latter  being  due 
to  the  state  of  the  portal  circulation.  The  congestion  of  the  liver 
interferes  with  its  secretions,  and  distension  of  the  portal  ramifi- 
cations in  the  stomach  and  intestine  induces  disturbance  of  their 
functional  integrity;  saHowness  or  even  jaundice  is  produced  and 
the  severe  gastric ^symptpmsi  which  we  have  previously  described. 
These  symptomr  are 'often  regarded  as  the  primary  disease,  and  the 
dropsy  of  the  abdomen  is  diagnosed  as  primary  instead  of  being 
secondary  in  character.  The  enlargement  of  the  liver,  the  jaundice, 
the  severe  flatulence,  disordered  appetite,  the  furred  tongue,  pain  at 
the  stomach,  all  tend  to  confirm  the  opinion  that  the  abdomen  is  the 
primary  source  of  the  disease.  As  a  rule  in  every  case  of  ascites  the 


520  ASCITES.       DROPSY. 

heart  and  lungs  should  be  carefully  examined.  The  same  remark 
may  be  made  in  reference  to  the  kidney;  the  chronic  congestion  leads 
to  an  albuminous  condition  of  the  urine,  and  this  may  be  regarded 
as  the  primary  malady.  Care  will,  however,  prevent  this  mistake. 
The  urine  is  generally  scanty,  of  a  deep  color  and  of  a  high  specific 
gravitv.  It  is  well,  to  remember  that  chronic  congestion  may  give 
rise  not  only  to  inflammation  of  the  surface  of  the  liver,  and  peri- 
hepatitis,  but  also  to  a  state  of  general  subacute  peritonitis. 

The  treatment  of  these  cases  is  often  attended  with  marked  relief; 
it  is  important  to  try  and  remove  the  cause  as  far  as  possible, 
whether  it  be  due  to  disease  of  the  heart  or  lungs,  and  thus  to  lessen, 
if  possible,  the  secondary  affection  and  remove  the  ascites.  The 
relief  of  the  latter  is  often  attended  with  marked  diminution  in  the 
symptoms  of  the  primary  disease ;  if  the  congestion  of  the  portal 
system  is  lessened,  that  of  the  liver  is  also  lessened  and  so  also  the 
distension  of  the  right  side  of  the  heart.  Having  lessened  the  cardiac 
oppression,  the  lungs  are  also  relieved,  the  heart's  action  becomes 
more  regular;  the  breathing  is  more  free,  and  the  patient's  distress 
proportionately  relieved.  The  treatment  of  the  secondary  affection 
is  often  more  important  than  that  of  the  primary  disease;  thus  it 
may  be  well  to  use  expectorants  to  lessen  the  bronchitis,  and  stimu- 
lants such  as  ether,  ammonia,  and  ardent  spirits  to  help  the  action 
of  the  heart,  so  also  digitalis  may  be  of  the  greatest  service;  but  if 
we  act  upon  the  abdominal  glands  so  as  to  increase  their  activity  we 
shall  more  effectually  lessen  the  primary,  whilst  we  remove  the 
secondary,  trouble. 

/  Purgatives  and  diuretics  should  be  used;  I  prefer  a  combination 
of  blue  pill,  or  calomel,  or  the  black  suboxide  of  mercury,  with  squill 
and  digitalis.  At  the  same  time  other  diuretics  should  be  given,  as 
the  acetate,  nitrate,  citrate,  or  iodide,  or  acid  tartrate  of  potassium, 
with  nitric  ether,  broorn,  &c.  If  the  bowels  are  confined  a  mercurial 
purgative  or  jalap,  or  scammony,  should  be  prescribed;  podophyllin 
or  elaterium  may  also  be  used,  or  the  saline  purgatives,  as  magnesia 
or  aperient  mineral  waters.  If  the  bowels  act  freely,  and  the  patient 
is  enabled  to  pass  three  or  four  pints  of  urine,  the  ascites  is  lessened, 
and  the  chest  affection  is  relieved.  The  gray  suboxide  of  mercury 
is  often  a  good  remedy  in  these  cases  in  one-grain  doses,  so  also  the 
copaiba  resin  in  ten  or  fifteen  grains  dissolved  in  spirit,  and  given  in 
mucilage  mixture.  The  gum  resins  and  turpentine  are  also  some- 
times of  service.  In  this  form  of  dropsy  tapping  is  less  necessary 
than  in  hepatic  ascites;  relief  is  afforded  by  the  means  we  have 
mentioned,  or  if  absolutely  necessary  the  legs  may  be  punctured, 
and  serum  allowed  to  drain  from  them.  There  is  a  greater  disposi- 
tion to  the  supervention  of  peritonitis  if  tapping  be  performed. 

The  third  form  of  ascites  is  that  which  follows  inflammation  of 
the  peritoneum,  inflammatory  or  peritoneal  ascites.  In  strumous  sub- 
jects, and  in  tubercular  disease,  serous  effusion  takes  place,  but  we 
are  now  referring  to  those  cases  in  which  there  is  no  such  cachexia. 
The  serous  membrane  becomes  inflamed,  and  pain  and  other  symp- 


ASCITES.      DROPSY.  521 

toms  of  peritoneal  disease,  with  serous  effusion  follow.     The  abdo- 
men is  rounded  and  tense,  and  there  may  be  general  uneasiness. 

The  diagnosis  of  these  cases  is  difficult,  for  the  disease  may  be 
confounded  with  strumous  peritonitis,  and  also  with  that  form  of 
peritoneal  mischief  in  which  the  serous  membrane  is  studded  with 
cancerous  tubera.  It  is  rather  by  negative  reasoning  than  by  direct 
symptoms  that  we  are  led  to  the  diagnosis;  the  occurrence  of  an 
acute  attack,  with  the  absence  of  other  exciting  causes  of  disease, 
either  in  the  thoracic  viscera  or  in  disease  of  glands,  as  the  liver  or 
kidney.  In  the  treatment,  diuretics  may  be  used,  but  purgatives 
only  with  caution.  The  abdomen  is  sometimes  with  advantage 
strapped  over  with  the  "Emplastrum  Ammoniaci  cum  Hydrargyro," 
which  tends  to  promote  absorption ;  the  disadvantage  of  this  appli- 
cation is  the  intolerable  itching  of  the  skin  that  it  often  induces.  It 
is  very  important  in  these  cases  to  improve  the  general  health. 

The  fourth  variety  of  ascites  is  that  which  is  due  to  disease  of  the 
(/lands,  the  liver,  the  kidneys,  the  spleen,  or  the  lymphatic  glands. 
We  have  already  referred  to  that  form  of  ascites  which  is  due  to 
secondary  congestion  of  the  liver,  and  it  is  not  our  intention  to  de- 
scribe all  the  S3'mptoms  of  hepatic  disease.  Many  forms  of  hepatic 
disorder  of  an  organic  kind  exist  without  any  dropsy  or  chronic 
enlargement,  enlargement  from  fatty  degeneration,  from  chronic 
obstruction  of  the  bile  ducts,  from  cancerous  disease,  hydatids,  &c., 
but  it  is  in  those  forms  of  disease  in  which  the  portal  circulation  is 
obstructed  that  effusion  takes  place.  We  have  mentioned  chronic 
disease  of  the  heart,  chronic  bronchitis,  and  emphysema;  the  same 
kind  of  obstruction  may  be  due  to  thrombus  or  to  the  pressure  of  a 
cancerous  growth,  but  the  disease  may  be  primarily  one  of  the  liver. 
In  chronic  inflammation  of  the  liver,  cirrhosis,  the  fibroid  tissue  of 
Glisson's  capsule  becomes  thickened;  the  liver  is  enlarged  and  con- 
gested, the  congestion  at  first  affecting  the  margin  of  the  lobules,  the 
portal  circulation,  rather  than  the  centre  of  the  lobule,  the  hepatic 
venous  circulation,  as  in  secondary  congestion.  As  the  effused  in- 
flammatory product  contracts,  the  circulation  through  the  vena  portae 
becomes  more  obstructed,  clusters  of  lobules  are  cut  off  from  other 
parts  and  give  the  gland  a  granular  appearance;  if  the  contraction 
be  seen  on  the  surface  of  the  liver  the  organ  has  an  irregular  aspect, 
and  when  the  contractions  are  more  decided  the  surface  has  been 
compared  to  one  studded  with  hob-nails,  hence  the  term  hob-nail 
liver.  When  contraction  thus  takes  place  the  venous  circulation  is 
more  interfered  with  than  the  arterial,  and  as  the  result  of  that  con- 
gestion asc^tes  is  produced,  and  the  abdomen  swells.  As  the  ob- 
struction increases  the  veins  communicating  with  the  general  venous 
circulation  become  enlarged,  and  the  superficial  epigastric  vein  of 
the  abdomen  returns  some  of  the  blood  from  the  lower  part  of  the 
abdomen  to  the  mammary  and  intercostal  veins,  and  in  this  way 
the  blood  reaches  the  vena  azygos  and  the  right  side  of  the  heart. 
The  haernorrhoidal  veins  also  communicate  with  the  branches  of  the 
iliac,  and  thus  relieve  the  vena  portae.  These  enlarged  veins  in  cir- 
rhosis are  seen  on  the  surface  of  the  abdomen;  and  from  the  congeg- 


522  ASCITES.       DROPSY. 

tion  of  the  hsemorrhoidal  veins  just  referred  to  there  is  a  tendency 
to  hemorrhage  from  the  rectum.  As  the  liver  contracts  there  is 
diminished  dulness,  which  may  not  reach  the  margin  of  the  ribs; 
and  with  this  condition  the  symptoms  gradually  increase  in  severity  ; 
bilious  attacks,  irritability  of  stomach,  disordered  appetite,  irregular 
bowels,  flatulence,  and  gradual  diminution  of  strength  are  produced; 
the  body  wastes,  but  the  abdomen  is  enlarged;  the  legs  are  thin, 
the  face  haggard,  the  capillary  veins  of  the  face  are  distinct,  the 
tongue  may  be  at  first  but  little  furred,  but  afterwards  it  becomes 
injected;  the  pulse  is  weak  and  irritable:  the  skin  is  sallow  or  semi- 
jaundiced;  the  patient  complains  of  weakness,  and  the  nights  are 
often  disturbed;  the  blood  becomes  changed  in  character,  it  coagu- 
lates feebly,  and  there  is  a  tendency  to  hemorrhage;  the  urine  is 
high  colored,  and  loaded  with  phosphates.  If  the  surface  of  the 
liver  be  also  inflamed  (peri hepatitis)  there  is  pain  in  the  right  side, 
and  often  still  more  decided  contraction;  it  becomes  rounded  at  its 
margin,  and  is  often  peculiarly  shrunken  as  wasting  increases.  This 
form  of  ascites  is  recognized  not  only  by  the  presence  of  the  symp- 
toms just  described,  but  by  the  absence  of  other  indications  of  dis- 
ease; there  is  no  evidence  of  pulmonary  nor  of  cardiac  disease,  no 
sign  of  renal  disease,  nor  of  tumor  pressing  upon  the  vena  portae, 
nor  of  enlargement  of  the  spleen  or  lymphatic  glands.  The  swelling 
begins  in  the  abdomen,  there  is  no  general  anasarca  as  in  acute  renal 
disease,  nor  do  the  legs  swell  as  in  cardiac  and  thoracic  disease. 

In  hepatic  dropsy  there  is  a  tendency  to  hemorrhage,  and  we  find 
that  bleeding  takes  place  from  the  nose,  sometimes  from  the  bowels; 
coffee-ground  vomit  from  the  stomach  indicates  slight  oozing  of  blood 
into  the  stomach  from  distended  capillaries  ;  sometimes  bleeding  takes 
place  from  the  gums;  and  it  is  always  advisable  to  avoid  any  sur- 
gical operation  if  possible,  for  even  the  puncture  of  paracentesis  may 
lead  to  troublesome  hemorrhage ;  the  clinical  history  enables  us  to 
distinguish  the  disease  from  purpura  haemorrhagica.  If  renal  disease 
be  also  present  there  is  more  general  anasarca,  and  the  urine  gives 
some  decided  evidence  of  the  presence  of  albumen.  It  is  sometimes 
difficult  to  distinguish  hepatic  dropsy  from  carcinomatous  disease  of 
the  peritoneum;  the  pain  may  be  mistaken  for  peri-hepatitis;  there 
is  absence  of  cardiac,  pulmonary,  and  renal  disease,  the  abdomen  is 
the  only  part  affected,  and  the  cancerous  cachexia  may  be  imper- 
fectly developed;  the  history  of  the  case,  however,  indicates  more 
acute  disease,  the  abdomen  is  more  tense,  there  is  less  bulging  in  the 
loins,  and  there  is  less  evidence  of  venous  obstruction. 

In  the  treatment  of  hepatic  dropsy,  we  must  remember  that  we 
have  to  do  with  disease  in  an  advanced  stage;  for  the  period  for  treat- 
ment of  chronic  inflammatory  disease  of  Grlisson's  capsule  is  before 
the  development  of  dropsy;  when,  however,  ascites  has  taken  place, 
we  may  endeavor  to  produce  absorption  by  the  use  of  diuretics,  as 
the  acetate,  nitrate,  or  iodide  of  potassium,  with  broom,  nitric  ether, 
squill,  and  mercurials  in  alterative  doses;  purgatives  may  be  given, 
and  iodine  applied  externally ;  in  every  case  the  diet  should  be  care- 
fully regulated,  and  stimulants,  if  possible,  avoided ;  but  it  will  be 


ASCITES.      DROPSY.  523 

found  that  diuretics  have  often  very  little  effect,  for  they  are  not  ab- 
sorbed on  account  of  the  distension  of  the  portal  veins;  copaiba  resin 
I  have  seen  of  service  in  increasing  the  quantity  of  urine;  and  some 
the  saline  purgative  mineral  waters  are  also  of  great  value      If 
purgatives  are  administered  freely  when  the  strength  is  exhausted 
the  effusion  will  often  be  found  to  increase:  jalap,  cream  of  tartar  and 
scammony  may  be  used;   the  podophyllin  resin  may  be  administered 
m  doses  of  one-third  of  a  grain  to  a  grain,  or  as  a  tincture,  one  grain 
being  dissolved  in  3,j  of  rectified  spirit,  and  HUY  to  ]x  given  difuted 
with  water  or  added  to  the  tincture  of  jalap;  it  is  a  good  plan  to  com- 
bine  a  laxative  with  a  tonic,  as  the  taraxacum  with  bark  or  the  in- 
fusion of  senna  with  that  of  gentian,  or  the  sulphate  of  magnesia  in 
small  doses  with  quinine.     If,  however,  these  remedies  have  failed 
and  the  patient  has  become  prostrate,  the  tongue  red,  the  pulse  fail- 
ing, the  stomach  irritable,  the  urine  scanty,  and  the  mind  distressed 
it  is  often  very  desirable  to  resort  to  paracentesis.     If  there  are  com- 
plications of  renal  or  splenic  disease,  and  if  the  peritoneum  has  be- 
come inflamed,  as  shown  by  the  pain  of  perihepatitis,  there  is  greater 
danger  of  peritonitis;   but  these  complications  need  not  necessarily 
preclude  the  operation.     In  those  instances  in  which  peritonitis  fol- 
lows paracentesis  abdominis,  we  must  not  expect  that  the  pain  of 
peritonitis  will  always  be  present;  the  patient  may  merely  seem  to 
be  prostrate,  his  tongue  dry  and  brown,  the  pulse  failing,  and  death 
may  take  place  apparently  from  exhaustion,  whilst  on  examination 
we  may  find  the  whole  of  the  serous  membrane  covered  with  lymph 
and  acutely  inflamed.     Where  the  umbilicus  has  become  distended, 
and  at  length  yields,  the  sudden  discharge  of  the  ascites  is  generally 
followed  by  peritonitis. 

In  ascites  connected  with  renal  disease,  the  serous  membrane  is 
often  changed  in  structure,  so  that  it  becomes  pale,  and  there  is  sub- 
acute  peritonitis;  the  countenance  is  pallid,  the  urine  is  albuminous; 
there  is  general  anasarca,  and  an  absence  of  svmptoms  of  hepatic! 
cardiac,  and  pulmonary  disease.  The  liver  and"  the  spleen  may  also 
be  affected,  as  in  lardaceous  disease;  there  is  no  difficulty  in  the  rec- 
ognition of  such  cases,  but  greater  difficulty  is  found  in  the  diagnosis 
of  chronic  cardiac  and  pulmonary  disease  in  which  the  kidney  has 
become  affected  by  secondary  congestion;  the  urine  in  such  cases  of 
thoracic  disease  is  scanty,  it  is  high  colored,  of  high  specific  gravity, 
and  when  the  congestion  of  the  right  side  of  the  heart  is  relieved, 
the  albumen  disappears.  It  would  be  foreign  to  our  purpose  to  enter 
upon  a  description  of  all  the  forms  of  renal  disease  and  their  treat- 
ment; it  will  suffice  to  remark  that  the  ascites  rarely  requires  separate 
treatment;  sometimes,  however,  the  distension  of  the  peritoneum  is 
so  great,  and  there  is  so  much  pressure  upon  the  stomach,  that  there 
is  excessive  vomiting,  and  scarcely  any  food  can  be  taken.  There 
may  be  violent  vomiting  simply  from  renal  disease,  but  it  is  more 
trying  when  the  stomach  is  compressed  by  ascitic  fluid.  In  the 
treatment  of  renal  ascites,  if  the  malady  be  acute,  benefit  is  derived 
from  diaphoretics,  as  acetate  of  ammonia,  with  antimony;  from  hy- 
dragogue  cathartics,  as  compound  jalap  powder  and  elaterium;  from 


624  ASCITES.      DROPSY. 

Turkish  and  hot-air  baths,  &c.,  but  when  the  disease  is  chronic,  these 
remedies  too  much  exhaust  the  patient,  and  saline  medicines,  with 
iron  or  quinine,  are  more  beneficial.  If  the  legs  are  very  oedematou? 
it  is  better  to  puncture  them,  and  in  this  way  to  relieve  the  ascites 
rather  than  to  perform  paracentesis  abdominis.  Care  is  required  lest 
erysipelatous  or  gangrenous  inflammation  supervene. 

Disease  of  the  spleen,  with  enlargement,  may  be  found  in  con- 
nection with  disease  of  the  liver  and  the  kidney,  as  in  lardaceous 
disease,  but  in  the  enlargement  with  ague  the  latter  glands  are 
unaffected,  and  there  may  be  no  ascites ;  in  leukaemia  or  leucocy  the- 
mia,  the  spleen  especially  is  enlarged  and  the  blood  is  altered  in 
character,  there  being  an  excess  of  white  corpuscles  or  leucocytes. 
In  the  latter  stages  of  this  disease  ascites  comes  on,  as  much,  how- 
ever, from  the  altered  condition  of  the  blood  as  from  any  primary 
affection  of  the  serous  membrane ;  the  patient  is  anasmic  and  the 
strength  gradually  fails;  the  heart  becomes  irritable,  and  there  is 
disturbance  of  digestion ;  sometimes  the  bowels  become  disordered 
and  diarrhoea  supervenes,  or  hemorrhage,  as  epistaxis,  may  come 
on ;  these  latter  symptoms  increase  the  exhaustion,  and  may  be  the 
immediate  precursor  of  a  fatal  termination.  The  cerebral  condition 
is  altered,  the  brain  is  irritable,  and  convulsions  may  follow.  The 
spleen  in  this  disease  attains  enormous  proportions,  and  as  it  in- 
creases in  size  passes  downwards  and  extends  towards  the  median 
line ;  it  becomes  tilted  forward  as  it  enlarges ;  the  notch  at  the  ante- 
rior border  becomes  very  distinct,  and  is  one  means  whereby  we 
may  recognize  the  enlarged  gland.  This  anterior  notch  may,  how- 
ever, be  simulated  by  a  mass  of  enlarged  glands,  and  great  enlarge- 
ment of  the  supra-renal  capsule  may  also  be  mistaken  for  enlarge- 
ment of  the  spleen.  Since  attention  was  drawn  to  this  form  of 
disease  by  Dr.  Hughes  Bennett  and  Professor  Virchow,  numerous 
instances  have  been  recorded,  and  the  pathological  changes  have 
been  noted,  but  the  treatment  has  not  been  attended  with  any  satis- 
factory result ;  the  malady  has,  in  most  cases,  steadily  progressed, 
and  has  terminated  fatally.  Iodide  and  bromide  of  potassium  have 
been  used,  and  by  some  strongly  recommended;  but  the  steady  use 
of  quinine  and  of  steel,  with  good  nourishment,  has  been  attended 
with  a  better  result,  although  the  benefit  has  only  been  temporary. 
Several  instances  have  been  recorded1  in  which  phosphorus  has  been 
used  by  Wilson  Fox,  Broadbent,  and  others,  but  without  results 
which  warrant  us  in  advocating  its  use.  The  anaemia  has  not  been 
checked  by  its  administration,  nor  is  life  prolonged.  Neither  has 
the  heroic  treatment  of  removing  the  gland  given  encouragement  to 
repeat  the  operation.  Mr.  Bryant  has  twice  removed  an  enormous 
spleen  in  cases  at  Guy's  Hospital,  but  each  patient  sank  in  a  few 
hours. 

In  general  enlargement  of  the  lymphatic  glands,  as  in  Hodgkin's 
disease,  there  is  less  affection  of  the  spleen,  in  fact  it  is  often  un- 
affected, whilst  the  glands  in  the  neck  and  in  the  axilla,  in  the  groin 

1  Clinical  Society's  Trans. 


ASCITES.       DROPSY.  525 

and  in  the  abdomen,  become  enormously  hjpertrophied ;  there  is 

Jess  tendency  to  ascites,  but  in  some  cases  of  enlargement  of  the 

abdominal  lymphatic  glands  there  is  an  effusion  of  serum  which 

from  the  chylous  vessels  becoming  implicated,  and  from  obstruction 

e  mesenteric  lymphatics,  becomes  of  a  milky  white  color     These 

instances  are  rare,  and  sometimes  the  milky  character  of  the  serous 

ion  may  be  regarded  as  an  accidental  condition  from  obstruction 

of  some  of  the  mesenteric  vessels,  the  disease  being  only  of  a  partial 

character;  m  other  instances  there  is  general  disease  of  the  mesen- 

snc  glands,  the  lymphatics  are  observed  as  whitish  cords  in  the 

mesentery  and  on  the  coats  of  the  intestine.     Disease  of  the  recepta- 

culura  chyli    or  pressure  upon  it  by  morbid  growths,  may  induce 

the  same  condition  of  chylous  dropsy. 

The  next  form  of  ascites  that  we  have  to  notice  is  that  which  is 
Found  m  connection  with  tubercular  disease  of  the  peritoneum  and 
with  strumous  disease.     This  disease  has  already  been  described  and 
we  need  not  fully  remark  upon  it.     It  will  be  sufficient  to  state  that 
the  malady  is  not  always  attended  by  the  same  symptoms:  in  some 
stances  the  deposition  of  tubercle  is  associated  with  considerable 
ittammatory  effusion,  the  intestines  become  adherent  and  matted 
together ;  ulceration,  perforation,  and  fecal  abscess  may  be  produced 
the  abdomen  becomiDg  large,  not  so  much  from  serous  effusion,  as 
from  distension  of  the  intestine.     In  other  cases  the  serous  effusion 
the  prominent  sign,  and  we  have  true  ascites.     In  a  third  class  of 
the  abdomen  becomes  very  large,  but  not  from  serous  effusion 
or  from  inflammatory  disease,  as  in  the  first  class,  but  without  pain 
sorile  excitement,  the  intestine  becomes  weak,  its  muscular  wall 
yields,  the  mesenteric  glands  may  be  enlarged,  and  we  have  the 
appearance   of  ascites,  but  without  the  reality;    the  abdomen  is 
resonant  everywhere.     It  is  therefore  only  in  the  second  class  that 
ropsy  of  the  peritoneum  really  exists.     The  symptoms  of  the  first 
class  we  have  already  described ;  in  strumous  ascites,  the  symptoms 
are  very  insidious ;  there  is  the  history  of  tubercular  disease ;  there 
5  impairment  of  general  health,  it  may  be  with  some  disease  of  the 
apices  of  the  lungs ;  the  abdomen  gradually  enlarges  without  pain  ; 
the  digestion  is  interfered  with,  and  the  bowels  are  inactive.     When 
this  condition  comes  on  in  young  women,  it  may  be  mistaken  for 
ovarian  dropsy.     As  to  the  treatment  of  these  cases  it  is  well  to 
improve  the  general  health,  to  act  freely  on  the  bowels,  and  to  use 
iodine,  internally,  in  the  form  of  iodide  of  potassium  or  iodide  of 
iron,  externally,  as  the  tincture  or  the  solution  of  iodine.     Cod-liver 
oil  should  be  given.     In  an  instance  of  this  kind  that  came  under 
my  notice  in  a  delicate  young  lady,  gentle  means  were  of  little  avail, 
but  the  effusion  disappeared  under  the  violent  but  dangerous  use  of 
drastic  purgatives  by  an  unqualified  practitioner. 

Cancerous  disease  of  the  peritoneum  is  another  cause  of  ascites ; 
we  do  not,  however,  refer  to  those  cases  of  cancerous  disease  in 
which  malignant  tumors  variously  located  interfere  with  the  venous 
circulation,  and  thus  cause  dropsy.  This  is  sometimes  the  case  in 
cancerous  disease  of  the  liver  and" of  the  glands  at  the  portal  fissure, 


526  ASCITES.      DROPSY. 

the  growth  may  invade  and  obstruct  the  vena  cava  and  thus  check 
the  return  of  blood.  There  is  an  interesting  class  of  cases  in  which 
the  peritoneum  is  especially  diseased  ;  the  serous  membrane  is 
studded  with  tubercles  varying  in  size  from  a  millet  seed  to  that  of 
a  pigeon's  egg;  the  tubera  are  soft,  sometimes  very  vascular  and 
composed  of  cancerous  cells;  the  mesenteric  glands  may  also  be 
involved,  and  sometimes  the  omentum  is  infiltrated  with  inflamma- 
tory and  cancerous  product,  so  that  it  is  thickened,  contracted,  and 
forms  a  dense  horizontal  band  immediately  beneath  the  stomach 
and  transverse  colon.  The  amount  of  inflammatory  product  varies 
exceedingly,  sometimes  a  layer  of  lymph  is  observed  on  the  serous 
membrane  ;  there  is,  however,  in  nearly  all  cases  a  large  amount  of 
serous  effusion  constituting  ascites,  and  it  is  often  discolored  by 
admixture  with  blood.  The  disease  probably  originates  in  the  sub- 
serous  lymphatic  vessels,  and  extends  till  the  whole  serous  mem- 
brane is  involved,  but  it  is  also  spread,  it  is  believed,  by  direct  con- 
tact of  one  part  with  another,  or  by  the  dislodgment  of  cells,  which 
become  attached  and  increase  at  the  point  of  their  fresh  adhesion. 
Sometimes  there  is  considerable  amount  of  dark  colored  pigment  in 
the  deposit,  and  the  growth  is  regarded  as  melanotic  in  character ; 
this,  however,  is  uncommon. 

We  refer  in  this  description  to  those  instances  in  which  the  peri- 
toneum is  especially  diseased,  for  in  many  cases  of  disease  of  the 
uterus  and  ovaries  the  serous  membrane  is  secondarily  involved,  so 
also  in  disease  of  the  stomach.  Dr.  Fagge  in  a  paper  in  the  'Guy's 
Hospital  Reports'  for  1875  gives  the  following  statistics.  In  45  cases 
of  disease  of  the  peritoneum  the  viscera  were  only  free  6  times;,  in 
19  cases  the  ovaries  were  affected,  and  17  the  stomach.  Of  these  17 
cases  7  were  without  disease  of  the  ovary,  but  in  10  disease  of  the 
ovaries  also  existed.  In  3  the  disease  appeared  to  commence  in  the 
uterus,  3  in  the  pancreas,  and  2  in  the  rectum.  In  the  45  only  11 
were  males. 

The  malady  is  one  affecting  persons  in  middle  and  advanced  life, 
and  the  subjects  of  it  are  generally  beyond  fifty  years  of  age :  it  is 
not  limited  to  women,  although  more  common  amongst  them,  as  we 
have  just  remarked.  The  general  health  of  the  patient  fails,  there 
is  weakness,  emaciation,  a  cachectic  appearance,  and  the  abdomen 
becomes  enlarged ;  the  rapidity  of  the  effusion  varies,  generally  it 
is  slow,  but  I  have  known  the  attainment  of  a  considerable  size  in 
three  or  four  weeks;  the  severity  of  pain  differs  considerably,  some- 
times it  is  slight,  at  other  times  very  distressing.  The  form  of  the 
disease  is  unlike  that  of  slow  and  passive  ascites ;  there  is  irritation 
of  the  serous  membrane,  the  recti  become  consequently  rigid,  and 
there  is  less  flaccidity  of  the  abdomen  ;  the  loins  are  less  distended, 
and  the  abdomen  is  more  prominent  anteriorly ;  the  abdominal  walls 
are  thin,  and  if  there  be  venous  obstruction,  the  veins  are  enlarged. 
As  prostration  increases  the  pulse  becomes  more  compressible,  the 
tongue  red  and  glazy,  and  diarrhoea  may  supervene ;  these  patients 
sink  from  exhaustion,  or  by  the  occurrence  of  more  severe  inflam- 
mation. 


ASCITES.       DROPSY.  52J 

The  disease  is  sometimes  mistaken  for  cirrhosis  in  consequence  of 
the  absence  of  disease  of  the  chest,  and  of  oedema  of  the  le's  the 
urine  also  being  free  from  albumen.  The  instances  most  difficult  of 
diagnosis  are  those  in  which  the  cancerous  disease  is  acute,  and  the 
pain  m  the  right  hepatic  region  resembles  perihepatitis.  in  a  case 

this  kind  under  my  care  m  the  clinical  wards  of  Guy's  Hospital 

Ihe*  nZ  t'TU  ti  ^^  SiXtj  J!arS  °f  a°6'  the  dlsease  was  a^te,' 
the  pain  in  the  right  side  pointed  to  hepatic  disease,  the  fluid  had 

collected  in  about  three  weeks,  and  he  sank  within  a  month  after 
admission;  the  cachectic  pallor  and  general  distress  were  different 
from  cirrhosis,  and  there  was  no  history  of  intemperate  habits  In 
women  the  disease  may  be  mistaken  for  ovarian  disease,  or  for  those 
cases  where  ascites  is  a  complication  of  the  ovarian  malady 

reatment  of  these  cases  is  unsatisfactory,  and  it  is  of  little 
avail  to  try  and  promote  the  absorption  of  the  fluid  by  diuretics  or 
by  purgative  medicines.  More  will  be  effected  by  soothino-  any 
irritable  condition  by  mild  doses  of  morphia,  by  the  use  of  tonics  as 
quimne,  or  by  iodide  of  potassium.  If  the  fluid  is  sufficient  greatly 
to  distend  the  abdomen  and  to  press  on  the  stomach,  it  may  be  well 
to  draw  it  off,  but  there  is  great  fear  that  exhaustion  may  rapidly 
supervene,  or  that  a  low  form  of  peritonitis  may  be  induced 

Ovarian  dropsy  is  the  last  form  that  we  have  to  notice,  and  we  do 
o  partly  because  ascites  is  sometimes  associated  with  it  and  because 
is  often  mistaken  for  peritoneal  dropsy.     It  would  be  foreign  to 
r  purpose  to  enter  into  the  pathology  of  ovarian  disease/we  would 
>nly  remark  that  the  disease  may  be  a  single  cyst  or  it  may  be  raulti- 
locular  with  varying  degrees  of  solid  deposit  in  the  walls;  sometimes 
T?P  ls  dense  and  fibrous,  and  non-malignant,  at  other  times  it 
has  all  the  characteristics  of  cancerous  disease ;  it  may  be  free  from 
adhesions,  or  the  cyst  may  be  firmly  fixed  to  adjoining  structures 
I  be  ovarian  tumor  begins  from  below,  and  is  generally  felt  in  one  or 
other  iliac  region;  it  is  dull,  and  if  full  of  fluid,  the  fluid  does  not 
gravitate  as  in  ascites.     There  is  dulness  in  front,  and  the  sides  are 
esonant  the  reverse  being  the  case  in  ordinary  ascites;  portions  of 
the  solid  walls  of  the  cyst  may  be  felt  in  some  cases  immediately 
low  the  liver  or  the  spleen,  but  the  hardness  can  be  more  easily 
moved  than  if  those  viscera  were  involved,  and  the  tumor  is  not 
affected  by  respiratory  movements.    It  is  in  cases  in  which,  with  the 
ovarian  cyst,  we  have  ascitic  fluid,  extending  to  the  loins,  that  diao-. 
s  sometimes  becomes  difficult.     The  fluid  in  the  cyst  may  be 
serous,  or  sero-sanguinolent;  the  albumen  contained  in  the  fluid  is 
different  from  that  found  in  peritoneal  effusion,  in  that  after  beino- 
coagulated  by  heat,  it  is  redissolved  by  acetic  acid  when  boiled  again. 
The  admirable  lectures  recently  given  by  Mr.  Spencer  Wells  at  the 
Eoyal  College  of  Surgeons,  and  published  in  the  'British  Medical 
Journal,'  refer  to  the  vatiety  of  cell  structures  found  in  these  ovarian 
fluids;  he  speaks  of  "the  ovarian    granule-cell"  described   by  Dr. 
Hughes  Bennett,  and  by  Dr.  Drysdale,  in  Dr.  Atlee's  work,  as  being 
rather  larger  than  the  red  blood-corpuscles,  and  he  refers  to  others^ 
which  show  the  more  or  less  malignant  character  of  the  disease. 


528  ASCITES.      DROPSY. 

We  have  already  referred  to  the  close  sympathy  which  exists 
between  the  stomach  and  the  ovary,  and  the  severity  of  the  vomit- 
ing and  other  gastric  symptoms  which  sometimes  occur  at  the  com- 
mencement of  ovarian  disease.  In  the  treatment  of  ovarian  dropsy 
it  is  useless  to  attempt  to  secure  the  absorption  of  the  fluid  by  diu- 
retics or  by  the  use  of  iodine  or  of  mercurials ;  if  there  be  inflamma- 
tion or  ascites,  much  may  be  done  to  relieve  these  conditions,  but 
the  ovarian  disease  will  not  be  lessened.  Small  doses  of  morphia 
will  sometimes  lessen  nervous  irritability  and  may  retard  the  pro- 
gress of  the  case,  but  if  the  disease  be  slight  it  is  better  not  to  dis- 
tress the  patient  by  treatment  which  will  do  more  harm  than  good. 
If  the  cyst  become  very  large  paracentesis  may  be  performed,  but  it 
is  only  a  palliative  measure.  The  fluid  will  re-collect,  and  the  only 
really  effectual  measure  is  to  remove  the  cyst.  Although  a  most 
formidable  operation  it  is  one  which  by  the  skill  of  modern  surgery 
is  attended  with  a  large  amount  of  success. 

In  the  remarks  that  we  have  made  upon  the  several  forms  of 
ascites  we  have  adverted  to  many  points  connected  with  diaynosis, 
and  it  is  not  necessary  again  to  dwell  upon  them.  So  also  as  to 
prognosis ;  the  ascites  is  so  generally  a  symptom  of  some  other  dis- 
ease, that  the  result  depends  in  great  measure  upon  the  original 
malady. 

The  treatment  must  also  be  according  to  the  cause  of  the  effusion. 
Diuretics  are  of  greater  service  in  the  ascites  from  chest  disease, 
than  in  that  from  cirrhosis  of  the  liver;  but  in  the  latter  disease,  it 
is  well  to  try  them,  for  in  some  cases  they  are  certainly  beneficial ; 
the  acetate  and  nitrate  of  potash  are  the  most  effective,  the  iodide 
may  be  used,  and  may  be  given  with  broom  juice.  The  copaiba 
resin  in  doses  of  ten  to  fifteen  grains  rubbed  down  with  a  little  recti- 
fied spirit,  and  given  in  a  mucilaginous  mixture,  is  a  valuable 
diuretic,  and  is  often  taken  by  patients  without  dislike.  The  mode- 
rate use  of  mercurials  is  sometimes  beneficial  in  the  early  stage  of 
dropsy  from  cirrhosis,  and  still  more  in  those  instances  of  obstructed 
hepatic  circulation  from  disease  of  the  heart  and  chronic  disease  of 
the  chest,  chronic  bronchitis,  and  emphysema.  Purgatives  are  of 
value,  and  sometimes  suffice  to  remove  the  fluid  from  the  serous 
cavity;  these  may  be  given  in  the  form  of  saline  aperients,  as  sul- 
phate of  magnesia,  or,  the  more  irritating  medicines  jalap  and  scam- 
mony,  and  sometimes  the  aperient  mineral  waters.  If  there  be 
peritoneal  irritation  and  inflammation  these  remedies  are  unsuitable. 
Blisters,  and  the  application  of  iodine,  may  serve  a  double  purpose, 
not  only  may  they  relieve  severe  pain,  but  they  may  promote  the 
absorption  of  the  fluid. 

It  will,  however,  be  frequently  found,  when  the  patient  is  ex- 
hausted from  chronic  disease  of  the  liver,  as  cirrhosis,  that  diure- 
tics and  purgatives  are  of  no  avail,  but  greater  benefit  is  derived 
from  the  use  of  tonics  with  gentle  aperients,  as  taraxacum  with  bark, 
or  quinine  with  sulphate  of  magnesia.  A  time  will,  however,  come 
when  the  question  of  drawing  off'  the  fluid  must  be  entertained,  and 


ASCITES.       DROPSY.  529 

the  operation  is  frequently  followed  by  the  greatest  amount  of  relief 
Sometimes  the  fluid  only  re-collects  very  slowly;  after  the  pressure 
on  the  abdominal  viscera  has  been  removed  the  kidneys  will  fre 
quently  act  freely,  and  that  without  any  diuretic.  The  operation 
of  paracentesis  should,  however,  be  postponed  if  there  be  evidence 
of  peritonitis  or  of  inflammation  on  the  surface  of  the  liver  peri- 
hepatitis ;  m  these  cases  there  is  greater  danger  of  peritonitis  When 
the  operation  is  decided  upon,  it  is  well  to  act  gently  on  the  bowels 
and  to  ascertain  that  the  bladder  is  empty,  the  fluid  mav  then  be 
drawn  off  by  trocar  and  canula,  the  patient  being  raised  up,  and  a 
flannel  bandage  placed  round  the  abdomen  to  give  support  as  the 
pressure  from  the  fluid  is  lessened.  After  the  operation  the  patient 
should  be  perfectly  quiet,  solid  food  should  be  avoided,  and,  if  neces- 
sary, an  opiate  given  to  insure  repose. 


34 


530 


CHAPTEK    XXI. 

ABDOMINAL  TUMORS. 

BEFORE  proceeding  to  the  consideration  of  true  abdominal  tumors, 
it  may  be  well  to  notice  those  which  are  of  a  delusive  character,  and 
have  been  called  by  Dr.  Addison  and  Sir  Wm.  Gull  "  phantom 
tumors."  It  is  a  common  thing  for  patients  to  suppose  that  there  is 
something  seriously  wrong  because  one  portion  of  the  abdominal 
walls  projects  more  prominently  than  another ;  sometimes  the  left 
hypochondrium  is  found  to  be  enlarged  from  a  flatulent  stomach,  or 
the  caecum  or  sigmoid  flexure  from  similar  gaseous  distension,  or  the 
abdominal  wall  yields  so  as  to  form  a  direct  protrusion ;  these  con- 
ditions are  easily  recognized,  the  part  is  found  to  be  flatulent  on  per- 
cussion, and  manipulation  fails  to  detect  any  solid  growth ;  but  in 
the  "  phantom  tumor,"  a  solid  mass  is  felt,  but  it  is  in  the  parietes, 
and  it  is  due  to  muscular  contraction  ;  the  part  is  hard  and  dense, 
and  may  be  readily  mistaken ;  it  is,  however,  fairly  resonant  on  percus- 
sion, and  by  gentle  and  continued  manipulation  the  muscle  relaxes; 
if  the  hand  be  gently  placed  on  the  hard  mass,  and  the  attention  of 
the  patient  diverted  by  conversation  of  an  absorbing  character,  at 
the  same  time  that  the  fingers  are  gently  moved  about  the  mass, 
the  hardness  disappears.  This  contraction  of  the  muscular  walls 
may  be  found  at  any  part,  sometimes  it  is  on  the  right  side,  and  the 
patient  seems  to  have  enlargement  of  the  liver ;  frequently  it  is  one 
of  the  transverse  muscular  bands  of  the  rectus,  sometimes  it  is  the 
quadratus  lumborum,  or  the  transversalis  muscle  of  the  abdomen. 

It  is  scarcely  correct  to  speak  of  a  loose  kidney  as  a  "  phantom 
tumor,"  it  is  a  movable  one,  but  it  does  not  entirely  disappear  by 
pressure,  although  it  may  pass  beyond  the  reach  of  the  hand. 

It  is  important  in  the  study  of  abdominal  tumors  to  have  a  defi- 
nite acquaintance  with  the  exact  position  of  the  abdominal  viscera. 
For  the  convenience  of  description,  the  abdomen  is  divided  into 
several  region  marked  out  by  lines  from  fixed  points.  A  line  drawn 
round  the  upper  part  of  the  abdomen  at  the  most  prominent  part  of 
the  costal  cartilages,  and  a  second  at  the  crest  of  the  ileum,  divide 
the  surface  into  three  zones,  and  these  again  by  two  perpendicular 
lines  are  subdivided  each  into  three  other  spaces,  the  lines  passing 
downwards  from  the  cartilage  of  the  eighth  rib  to  the  middle  of 
Poupart's  ligament.  In  the  upper  zones  we  have  the  right  and  left 
hypochondriac  regions,  on  either  side  of  the  epigastric  space  or  scro- 
biculus  cordis;  in  the  central  zone,  the  right  and  left  lumbar  regions 
are  on  either  side  of  the  umbilical,  and  below,  in  the  third  zone,  the 
right  and  left  iliac  are  situated  on  either  side  of  the  hypogastric  re- 
gion. During  health  these  regions  are  occupied  by  their  respective 


ABDOMINAL    TUMORS.  531 

viscera,  and  it  is  useless  to  try  and  ascertain  abnormal  states,  unless 
there  be  a  thorough  knowledge  of  that  which  is  normal.  We  would 
further  add,  that  in  every  case  of  abdominal  tumor  it  is  important 
to  inquire,  1st,  into  the  general  history  of  the  symptoms  of  the 
patient ;  2d,  to  ascertain  the  exact  position  of  tumor,  and  the  physical 
signs ;  and  3d,  to  learn  whether  there  is  any  functional  disturbance 
pi  the  abdominal  organs.  It  is  not  likely  that  any  viscus  is  involved 
ma  morbid  growth,  if  it  perform  its  functions  in  a  healthy  manner. 
It  may  be  well  to  consider  these  regions  as  regards  their  normal 
and  abnormal  contents.  The  right  hypochondrium  contains  especially 
the  liver  and  gall-bladder,  but  the  gland  passes  into  the  epigastric 
region,  and  reaches  the  left  hypochoudrium ;  when  enlarged  it  ex- 
tends into  the  umbilical  and  right. lumbar  regions.  The  liver  is 
attached  to  the  diaphragm,  and  to  a  certain  extent  moves  with  it. 
It  reaches  upwards  as  high  as  the  fifth  rib,  where  the  dulness  com- 
mences and  is  partial,  at  the  sixth  rib  the  dulness  is  complete  ;  when 
the  patient  is  recumbent  the  liver  is  behind  the  ribs,  unless,  as  is 
generally  the  case  in  women,  it  has  been  pushed  down  by  compres- 
sion, but  in  the  erect  and  sitting  postures  the  liver  may  be  felt  an 
inch  below  the  ribs.  Beside  the  liver  and  gall-bladder  the  right 
hypochondrium  contains  the  angle  of  the  ascending  colon,  par?  of 
the  duodenum,  the  right  supra-renal  capsule,  and  the  upper  part  of 
the  right  kidney.  It  must  be  remembered  in  reference  to  .enlarge- 
ment of  the  liver  that  the  gland  may  be  pushed  down  by  pleuritic 
effusion.  In  large  effusions  into  the  right  pleura  the  liver  is  always 
displaced. 

2.  The  liver  may  be  pushed  down  by  effusion  between  the  upper 
lobe  and  the  diaphragm,  the  effusion  being  either  serous  or  puru- 
lent;  in  these  cases  the  symptoms  may  closely  resemble  pleuritic 
effusion.     Many  years  ago  a  woman  was  admitted  under  my  care 
into  Guy's  Hospital  with  severe  peritoneal  symptoms  after  a  fall 
from  a  cart  upon  the  abdomen.     The  pain  was  great,  and  the  strength 
gradually  gave  way.     On  examination  of  the  lower  part  of  the  right 
lung  before  death,  dulness  on  percussion,  with  bronchial  breathing 
and  modified  voice  sound  was  heard,  and  some  who  had  not  known 
the  previous  history  believed  the  disease  to  be  above  the  diaphragm. 
On  the  post-mortem  table  a  trocar  was  introduced  between  the  ribs 
posteriorly  and  pus  exuded,  apparently  confirming  the  idea  that 
empyema  existed,  but  on  fuller  examination  it  was  found  that  the 
pus  was  situated  between  the  liver  and  the  diaphragm ;  there  had 
been  peritonitis,  and  the  pus  was  circumscribed  by  adhesions. 

3.  The  liver  may  be  pushed  down  by  the  development  of  tumors, 
or  by  a  hydatid  cyst  in  the  right  lobe  of  the  liver.     This  cyst  o>r 
tumor  may  be  so  situated  behind  the  ribs  as  to  be  quite  beyond  the 

Breach  of  the  hand.  A  woman  in  middle  life  was  admitted  under 
/  my  care  into  Guy's  with  the  liver  extending  into  the  umbilical 
region,  the  surface  was  smooth,  the  gland  passed  lower  into  the 
abdomen,  and  the  strength  of  the  patient  at  length  gave  way  and 
she  sank.  On  examination,  when  the  abdomen  was  opened,  the 
liver  seemed  to  fill  the  greater  part  of  the  abdomen  on  the  right 


532  ABDOMINAL    TUMORS. 

side;  the  surface  was  smooth,  and  it  was  only  when  the  gland  was 
drawn  down  from  the  diaphragm  that  the  true  nature  of  the  enlarge- 
ment was  recognized.  An  enormous  hydatid  cyst  occupied  the  right 
lobe  and  pressed  in  every  direction,  but  did  not  reach  the  free  sur- 
face of  the  liver.  In  the  examination  of  an  enlarged  liver  the  patient 
should  be  placed  on  the  back,  the  knees  drawn  up,  and  the  head 
comfortably  supported,  and  the  patient's  attention  should  be  absorbed 
by  conversation,  if  possible.  Sudden  pressure  will  often  detect  an 
enlarged  gland,  which  could  not  be  recognized  by  gradual  pressure; 
if  the  ringers  be  passed  upwards  from  below,  the  edge  may  be  caught, 
and  they  should  then  be  gently  passed  over  the  gland  to  ascertain 
whether  there  are  any  irregularities;  the  surface  is  dull  on  percus- 
sion; at  the  upper  part  where  the  liver  is  overlapped  by  lung  there 
is  partial  resonance,  and  we  sometimes  find  that  the  lower  edge  may 
be  covered  by  the  colon,  and  resonance  is  thus  produced. 

4.  Enlargement  of  the  gall-bladder  is  found  generally  opposite  the 
tenth  rib,  it  is  pyriform  and  when  filled  with  bile  will  yield  some- 
what to  pressure.     Sometimes  I  have  found  it  filled  with  a  great 
number  of  gall-stones,  so  that  it  resembled  a  solid  mass;  a  very  dif- 
ferent condition  was  found  some  years  ago  in  a  case  under  the  late 
Dr.  Babington,  the  specimen  of  which  is  in  Guy's  Museum ;  the  gall- 
bladder communicated  with  the  intestine  and  was  filled  with  gas,  so 
that  there  was  resonance  on  percussion. 

5.  Enlargement  of  the  liver,  if  general,  arises  from  congestion, 
from  inflammation,  from  fatty  deposit,  from  lardaceous  disease,  from 
obstruction  of  the  bile-ducts;    if  local,  from  hydatid  tumor,  from 
syphilitic  deposit,  from  cancerous  growths,  from  abscess  in  the  liver, 
or  from  suppuration  in  connection  with  the  bile-ducts. 

6.  An  enlargement  of  the  right  kidney  can  sometimes  be  felt 
immediately  below  the  right  lobe  of  the  liver;  it  will  be  found  to 
extend  into  the  loin. 

7.  Malignant  disease  of  the  right  supra-renal  capsule  may  also 
reach  the  lower  part  of  the  liver.     I  have  found  a  tumor  of  the  left 
supra-renal  capsule  simulating  enlargement  of  the  spleen. 

8.  Malignant  disease  of  the  pancreas  and  first  part  of  the  duode- 
num are  recognized  by  their  clinical  history ;  the  hardness  may  be 
felt  closely  in  contact  with  the  liver. 

9.  Cancerous  disease  of  the  angle  of  the  ascending  colon  is  also 
felt  in  this  region;  in  this  disease  pain  comes  on  several  hours  after 
food,  and  there  is  likely  to  be  discharge  of  blood  or  of  mucus  from 
the  bowels. 

In  the  epigastric  region  we  find  the  stomach  and  its  lesser  curva- 
ture, and  the  left  lobe  of  the  liver ;  the  gall-bladder  and  the  pyloric 
extremity  of  the  stomach  are  situated  at  its  union  with  the  right 
hypochondriac  region ;  posteriorly  we  have  the  pancreas,  the  aorta, 
the  vena  cava,  the  coeliac  axis  and  the  commencement  of  its  large 
branches;  at  the  lower  part  of  this  region  we  have  the  transverse 
colon,  varying,  however,  in  position  according  to  the  distension  of 
the  stomach.  We  would  remark  that  yielding  of  the  parietes,  with 


ABDOMINAL    TUMORS.  533 

flatulent  distension  of  the  stomach,  often  gives  rise  to  the  idea  of 
tumor. 

2.  Abscess  sometimes  forms  in  the  parietes  in  this  part  not  only 
m  the  muscular  parietes,  but  in  the  loose  cellular  tissue  about  the 
end  of  the  sternum.     In  a  case  of  that  kind  in  the  clinical  ward  of 
Gruy  s  some  years  ago,  there  was  a  projection  at  the  scrobiculus  cordis 
which  was  afterwards  found  to  be  an  abscess  which  extended  to  the 
under  surface  of  the  diaphragm. 

3.  Abnormal  pulsation  is  often  felt  at  the  epigastric  region ;  this 
may  arise  from  an  aneurismal  tumor  in  connection  with  the  aorta 
or  with  the  cceliac  axis;  in  aneurism  of  the  aorta  close  to  the  dia- 
phragm it  is,  however,  very  difficult  to  feel  the  aneurismal  tumor 
unless  it  be  of  large  size.    In  the  majority  of  cases  a  pulsating  tumor 
at  the  scrobiculus  cordis  is  found  to  arise  from  disease  of  the  left 
lobe  of  the  liver  pressing  upon  the  abdominal  aorta;  in  other  cases 
the  pulsating  mass  may  consist  of  a  vascular  and  pulsating  medullary 
growth  in  the  stomach. 

4.  Tumors  of  different  kinds  in  the  left  lobe  of  the  liver  are  found 
in  this  region. 

5.  Disease  at  the  lesser  curvature  of  the  stomach  may  not  only  be 
felt  in  this  region,  but  may  have  pulsation  communicated  to  it  from 
the  aorta. 

6.  Chronic  ulcer  with  thickened  walls  may  constitute  the  tumor 
felt  at  the  epigastric  region ;  but 

7.  A  hard  mass  felt  in  the  epigastrium  is  more  frequently  found 
to  be  malignant  disease. 

On  a  level  with  the  umbilical  line  and  situated  posteriorly  we  have 
the  pancreas,  but  so  deeply  is  the  gland  placed  that  it  is  difficult  to 
recognize  enlargement  by  digital  examination. 

Malignant  disease  of  the  pancreas  where  there  is  much  enlarge- 
ment may  be  sometimes  recognized,  but  in  such  cases  we  principally 
depend  upon  the  clinical  history  and  the  general  symptoms,  in  form- 
ing a  correct  diagnosis.  In  a  case  of  inflammation  of  the  cellular 
tissue  about  the  pancreas  which  I  saw  in  consultation  some  years 
ago,  there  was  a  hard  swelling  felt  at  the  upper  part  of  this  region ; 
there  was  severe  pain,  with  febrile  excitement,  and  I  supposed  the 
case  was  one  of  gastric  disease ;  post-mortem  examination  showed 
that  the  stomach  was  healthy,  but  that  the  swelling  was  an  abscess 
connected  with  the  pancreas. 

In  chronic  disease  of  the  omentum,  often  of  a  malignant  character, 
the  serous  membrane  is  puckered  and  drawn  upwards,  so  that  it 
forms  a  firm  band  passing  across  the  abdomen,  at  the  lower  part  of 
the  epigastric  or  at  the  upper  part  of  the  umbilical  region.  It  may 
be  associated  with  malignant  disease  of  the  peritoneum,  as  we  have 
mentioned. 

In  the  left  hypochondrinm  we  have  the  cardiac  extremity  of  the 
stomach,  the  spleen,  the  left  supra-renal  capsule,  and  a  portion  of  the 
kidney.  The  left  angle  of  the  colon  may  also  extend  to  this  space. 
The  most  common  tumor  found  in  this  region  is  the  spleen,  which 
as  it  increases  in  size  not  only  passes  upward  and  raises  the  level  of 


534  ABDOMINAL    TUMORS. 

dulness  on  that  side,  but  it  passes  downwards  and  is  also  directed 
forwards.  This  forward  direction  may  be  due  to  the  band  of  perito- 
neum immediately  beneath  the  gland,  but  there  is  no  doubt  of  the 
fact  that  the  spleen,  as  it  increases,  and  it  attains  sometimes  an 
enormous  size,  passes  not  only  into  the  lumbar  but  also  into  the 
umbilical  region.  The  fissure  at  the  anterior  edge  assists  us  in  the 
recognition  of  the  spleen,  but  this  is  not  a  certain  sign,  for  the  fissure 
between  two  enormously  enlarged  lymphatic  glands  may  communi- 
cate to  the  touch  the  same  impression.  The  spleen  enlarges  after  a 
full  meal ;  it  may  increase  from  temporary  portal  congestion ;  it  is 
felt  below  its  normal  position  in  enteric  and  other  fevers,  but  these 
conditions  would  not  be  designated  as  tumors.  It  is  in  the  enlarge- 
ment after  ague,  in  leucocythemia,  in  lardaceous  disease,  that  we 
find  the  spleen  to  attain  to  very  large  proportions,  and  in  these  cases 
the  increase  is  general.  In  abscess,  in  hydatids,  and  in  malignant 
disease,  the  enlargement  is  partial. 

2.  Another  turnor  in  the  left  hypochondrium  arises  from  enlarge- 
ment of  the  left  kidney  or  from  hydatid  at  that  part,  but  in  this  case 
the  growth  extends  more  into  the  loin,  and  there  is  more  likelihood 
of  distension  of  the  lower  ribs  on  that  side. 

3.  Malignant  disease  of  the  supra-renal  capsule  on  the  left  side 
sometimes  presses  forward  to  the  anterior  part,  and  is  felt  immedi- 
ately below  the  spleen.     I  have  known  it  mistaken  for  an  enlarge- 
ment of  the  spleen  itself,  for  the  growth  was  large,  and  i$  appeared 
to  pass  from  beneath  the  ribs. 

4.  Aneurismal  disease  at  the  commencement  of  the  descending  aorta 
sometimes  pushes  forward  the  spleen,  and  the  diagnosis  is  difficult. 
In  the  case  to  which  I  refer,  the  lower  ribs  were  prominent,  but  pul- 
sation was  very  indistinct.     The  patient  died  from  rupture  of  the 
aneurismal  sac  behind  the  peritoneum. 

5.  The  solid  walls  of  an  ovarian  cyst  sometimes  reach  into  the  left 
hypochondrium,  form  a  tumor,  and  simulate  disease  of  the  spleen. 
The  tapping  of  the  cyst  would  be  one  means  of  diagnosis  of  a  case 
of  this  kind,  for  the  solid  portion  of  the  cyst  would  then  pass  towards 
the  pelvis. 

6.  It  is  scarcely  necessary  to  mention  the  manner  in  which  the 
spleen  may  be  pushed  down  by  effusions  both  into  the  pleura  and 
into  the  pericardium. 

7.  Local  suppuration  may  occur  in  this  region  and  produce  a  swell- 
ing resembling  a  tumor. 

The  next  zone  of  the  abdomen  is  divided  into  the  central,  the  um- 
bilical, and  into  the  right  and  left  lumbar  spaces.  In  the  ln.mbar 
regions  the  kidneys  and  the  ascending  and  descending  colon  may  be 
causes  of  tumors.  The  kidneys  extend  to  the  loin,  and  as  they  pass 
forward  can  be  felt  anteriorly  to  the  inner  side  of  the  colon.  The 
condition  of  the  urine,  in  the  discharge  of  blood,  of  pus,  or  of  cancer- 
ous cells,  affords  to  us  an  important  guide  in  diagnosis.  A  tumor 
from  distended  pelvis  of  the  kidney  is  most  uncertain  as  to  its  size. 
Sometimes  a  calculus  may  block  up  the  ureter,  and  the  pelvis  of  the 
kidney  gradually  attains  large  dimensions,  till  at  length  the  ureter 


ABDOMINAL    TUMORS.  535 

is  distended  beyond  the  size  of  the  obstructing  calculus,  and  a  sudden 
discharge  of  several  pints  of  urine  at  once  diminishes  the  size  of  the 
tumor.  The  same  may  be  the  case  in  suppuration  of  the  kidney. 
In  a  patient  under  my  care  in  Guy's,  a  large  tumor  extended  from 
the  right  lumbar  into  the  iliac  region,  and  would  suddenly  subside  on 
the  discharge  of  several  pints  of  urine.  This  condition  came  on 
when  the  patient  was  about  sixteen;  he  was  a  shoemaker,  and  al- 
though he  had  several  severe  attacks,  he  continued  his  work  till  he 
was  nearly  sixty-four  years  of  age,  when  he  died  in  Guy's  Hospital 
from  a  large  cancerous  growth  which  affected  the  kidney  on  the  same 
side.  After  death  it  was  found  that  a  calculus  was  the  cause  of  the 
obstruction  of  the  ureter. 

2.  The  glands  in  connection  with  the  kidney,  the  lumbar  glands, 
sometimes  form  a  large  tumor  in  this  region;  the  urine  is  then  unaf- 
fected, the  growth  is  more  irregular,  and  there  are  generally  other 
indications  of  malignant  disease.     In  hydatid  disease  of  the  kidney 
the  tumor  is  rounded  and  elastic. 

3.  Accumulations  in  the  ascending  or  descending  colon  form  masses 
in  these  regions,  but  the  clinical  history,  the  absence  of  severe  symp- 
toms, and  the  relief  by  purgative  medicine,  characterize  these  cases. 

4.  In  intussusception  a  doughy,  elongated  mass  may  be  felt  in  the 
ascending  or  even  in  the  descending  colon.     The  severe  and  spasmo- 
dic pain,  the  vomiting  which  is  often  present,  the  obstruction  of  the 
bowels,  and  the  discharge  of  blood  and  of  mucus,  indicate  the  charac- 
ter of  the  affection. 

5.  In  diseases  of  the  spine  leading  to  suppuration  there  is  a  bulging 
in  the  loin,  and  it  may  be  a  projection  anteriorly,  which  can  be  felt 
on  digital  examination. 

6.  Abscess  in  the  loin  and  in  the  quadratus  lumborum  muscle  may 
lead  to  enlargement,  and  may  extend  into  the  bowel.     Thus,  we  have 
known  an  abscess  pass  into  the  caecum,  and  have  seen  suppuration 
primarily  connected  with  the  bowel  reach  the  loin. 

7.  Ovarian  tumors  may  pass  from  the  iliac  fossa  into  the  loin,  but 
more  frequently  they  extend  into  the  umbilical  region. 

In  the  umbilical  region  we  have  the  transverse  colon  and  the 
ornentum  attached  to  it,  the  small  intestine,  with  the  mesentery  and 
mesenteric  glands,  and  posteriorly  the  aorta  and  vena  cava.  On 
either  side  are  the  right  and  left  renal  vessels.  The  position  of  the 
transverse  colon  varies  greatly ;  sometimes  its  curve  is  greatly  in- 
creased, and  it  may  reach  nearly  to  the  hypogastric  region.  The 
curve  may  be  increased  as  the  consequence  of  distension,  or  by  the 
dragging  of  an  omental  hernia.  Tumor  in  the  walls  of  the  intestine 
also  changes  its  position. 

2.  Intussusception  of  the  small  intestine  is  often  found  in  the  um- 
bilical region. 

3.  Tumors  in  the  omentum  and  in  the  mesentery.    In  the  former, 
the  mass  is  movable,  and  there  is  no  functional  disturbance  of  the 
intestine. 

4.  In  strumous  disease  of  the  intestine  the  bowels  are  often  matted 
together  by  inflammatory  adhesion,  and  the  mass  resembles  a  tumor. 


536  ABDOMINAL    TUMORS. 

Sometimes  there  is  suppuration  or  fecal  abscess,  or  it  may  be  the 
discharge  takes  place  from  the  umbilicus. 

5.  Ovarian  tumors  are  often  found  to  extend  into  the  umbilical 
region. 

6.  Aneurismal  disease  of  the  aorta  and  the  branches  of  the  abdo- 
minal aorta  may  be  felt  in  this  space,  but  frequently  enlarged  glands, 
pressing  upon  the  aorta  or  upon  the  renal  arteries,  simulate  true 
aneurismal  disease.     Sometimes  we  can  remove  the  gland  from  the 
pulsating  vessel  beneath,  by  manipulation  or  by  changing  the  posi- 
tion of  the  patient,  but  this  is  not  invariably  the  case. 

In  studying  enlargement  in  the  loins  it  is  important  to  remember 
that  both  the  ascending  and  descending  colon  closely  sympathize 
with  diseased  structures  before  or  behind  them,  the  intestine  becomes 
inactive,  the  passage  of  the  contents  impeded,  and  the  fulness  may 
resemble  primary  tumor  of  the  bowel. 

The  remaining  regions  are  the  hypoyastric  and  the  right  and  left 
iliac. 

In  the  hypogastric  region  whenever  a  tumor  is  felt  we  must  always 
render  ourselves  sure  that  the  bladder  is  not  distended.  Urine  may 
pass  constantly,  in  fact,  there  may  be  a  constant  dribbling  from  over- 
distension  of  the  bladder,  and  thus  the  disease  be  unsuspected.  In 
this  way  I  have  known  the  bladder  reach  above  the  umbilicus  and 
contain  many  pints  of  urine. 

2.  Enlargements  of  the  uterus,  whether  from  pregnancy  or  turner, 
extend  into  the  hypogastric  region. 

3.  Fibroid  tumors  of  the  uterus  and  of  the  ovaries,  and  cystiform 
disease  of  the  ovaries,  extend  into  right  or  left  iliac  region,  and  also 
into  the  central  space. 

4.  Hydatid  disease  of  the  cellular  tissue  in  connection  with  the 
bladder  forms  a  rounded  tumor  in  this  space,  in  touch  very  closely 
resembling  a  distended  bladder. 

5.  Aneurismal  disease  of  the  iliac  vessels  must  also  be  borne  in 
rnind  as  a  cause  of  tumor  in  the  lateral  portions  of  the  hypogastric 
region. 

In  the  riyht  iliac  region  we  have  the  caecum  and  its  appendix,  and 
diseases  of  these  structures  constitute  many  of  the  morbid  enlarge- 
ments at  this  part.  The  mischief  may,  however,  be  external  to  the 
caecum,  peri- typhlitis;  in  these  diseases  we  have  local  pain  and 
tenderness,  febrile  excitement,  generally  a  disordered  condition  of 
the  bowels,  constipation,  sickness,  and  it  may  be  peritonitis.  In 
tumor  from  enlarged  glands,  there  is  less  interference  with  the  action 
of  the  bowels.  In  pelvic  abscess  the  bowel  is  free,  the  mischief  is 
found  to  extend  from  above,  and  it  passes  onwards  in  the  direction 
of  the  psoas  and  iliacus  muscles.  A  tumor  from  renal  disease  may 
reach  the  iliac  fossa,  but  it  can  be  traced  upwards,  and  the  urine  will 
be  found  to  be  diseased  in  most  cases,  if  carefully  examined,  except 
in  instances  in  which  one  kidney  does  the  entire  work  and  the  other 
is  completely  shut  off. 

An  aneurismal  tumor  from  disease  of  the  iliac  vessels  is  recognized 


ABDOMINAL    TUMORS.  537 

by  its  pulsatile  and  expansive  character,  and  by  the  condition  of  the 
circulation  of  the  limb. 

Ovarian  tumors  reach  to  the  right  or  left  loin;  sometimes  they 
become  adherent  to  the  bowel,  and  I  have  known  an  ovarian  cyst 
become  adherent  to  the  caecum,  and  having  discharged  its  contents 
into  the  bowel,  the  cyst  has  become  filled  with  fecal  matter.  Acute 
disease  of  the  right  ovary  sometimes  closely  resembles  typhlitis,  but 
the  pain  is  lower,  it  extends  into  the  pelvis;  the  tenderness,  the  con- 
stipation, the  febrile  excitement,  may  be  equally  marked  in  the  acute 
disease  of  the  ovary,  as  in  cascal  disease. 

In  the  left  iliac  region  many  morbid  growths  correspond  to  those 
on  the  right  side,  but  here  the  sigrnoid  flexure  takes  the  place  of 
the  caecum.  The  curvature  of  this  part  of  the  bowel  varies  greatly  ; 
sometimes  the  sigrnoid  flexure  extends  to  the  right  side,  and  there 
may  be  adhesion  to  the  caecum.  In  other  cases  of  distension  it 
bends  upon  itself,  it  falls  into  the  pelvis,  and  the  acute  bending  at 
a  right  angle  leads  to  obstruction.  The  termination  of  the  sigmoid 
flexure  in  the  rectum  at  the  brim  of  the  pelvis  is  the  part°often 
affected  by  disease,  and  a  tumor  can  in  most  cases  be  made  out  by 
careful  manipulation.  Sometimes  there  is  a  rounded  growth  in 
connection  with  the  mucous  membrane  of  the  bowel,  at  other  times 
all  the  coats  are  thickened  and  contracted,  as  if  a  piece  of  string  had 
been  tied  round  the  bowel ;  all  these  states  lead  to  gradually  increas- 
ing obstruction,  which  may  become  complete. 

Inflammatory  adhesion  sometimes  takes  place  between  the  sigmoid 
flexure  and  the  bladder;  an  external  tumor  is  felt  on  deep  but  gentle 
manipulation.  The  diagnosis  and  the  prognosis  of  these  cases  are 
often  very  obscure,  and  in  several  we  have  known  direct  communica- 
tion take  place  with  the  bladder,  and  fecal  discharge  with  the  urine 
supervene.  Colotomy  is  of  the  greatest  service  in  these  cases. 

We  have  thus  briefly  sketched  the  site  and  the  character  of  abdo- 
minal tumors;  each  case  has  a  clinical  history  of  its  own,  and  it  is 
by  the  careful  study  of  that  history,  in  connection  with  the  position 
of  the  tumor  and  the  disturbances  of  the  functional  activity  that  are 
associated  with  it,  that  we  can  make  out  the  true  nature  of  the  dis- 
ease. Many  most  interesting  cases  of  abdominal  tumor  might  have 
been  added  to  this  chapter;  the  difficulties  in  the  diagnosis  might 
thereby  have  been  more  fully  indicated,  and  the  various  modes  of 
relief  discussed ;  but,  we  have  refrained  on  account  of  the  length  to 
which  this  work  has  already  extended,  and  we  have  only  given  the 
general  facts  which  these  instances  of  disease  have  brought  out. 

We  have  sought  to  show  the  leading  characteristics  of  diseased 
conditions  as  manifested  in  the  various  portions  of  the  alimentary 
canal ;  and  to  do  this  have  recorded  the  cases  themselves,  as  facts 
upon  which  each  one  may  form  his  own  opinion,  rather  than  depend 
entirely  upon  the  deductions  we  have  drawn  from  them.  Such  gene- 
ral conclusions  in  most  chapters  have  preceded  the  cases  upon  which 
they  are  founded;  and  we  leave  them  before  our  readers  with  the 
hope  that  they  will  serve  further  to  elucidate  the  general  symptoms, 
pathology,  and  treatment  of  diseases  of  the  alimentary  canal. 


ILLUSTRATIVE  CASES. 


CASE 

I — Diffused  Inflammation  of  the  Throat. 
II — Diffused  Inflammation  of  the  Throat.      Ulceration  of  the 

Pharynx. 

Ill — Carcinoma  of  the  Throat.     Tubercular  Pneumonia. 
IV — Diseased   Cartilages  of  the  Trachea.      Ulceration  of  the 

(Esophagus. 

V — Ulceration  of  the  (Esophagus.     Perforation  of  the  Trachea. 
VI — Dysphagia.     Mania. 
VII — Spasmodic  Affection  of  the  (Esophagus. 
VIII — Stricture  of  the  (Esophagus. 
IX — Stricture  of  the  (Esophagus. 
X — Cancerous  Disease  of  the  Lower  Third  of  the  (Esophagus. 

Division  of  the  Canal.     Death  from  Bronchitis. 
XI — Cancer  of  the  (Esophagus.     Sloughing  Pneumonia.     The 

Pneumogastric  Nerve  involved. 
XII — Cancer  of  the  (Esophagus,  of  the  Cervical  Glands,  and  of 

the  Thyroid  Body.     Gangrene  of  the  Lung. 

XIII — Epithelial  Cancer  of  the  (Esophagus,  Pancreas,  Liver,  and 
Kidneys.  The  Pneumogastric  Nerves  involved.  Granu- 
lar Kidneys.  Chronic  Pleuro-pneumonia  with  Cancer. 
Fibrous  Tumor  in  the  Uterus.  Cancer  of  Supra-renal 
Capsules  and  Semilunar  Ganglion. 

XIV — Epithelial  Cancerous  Tumor  in  the  Pharynx,  closing  the 
entrance  into  the  (Esophagus.     Effusion  of  False  Mem- 
brane in  the  Larynx  and  Trachea.     Acute  Bronchitis. 
XV — Carcinoma  of  the    (Esophagus,   communicating   with  the 

Trachea.     Cancer  of  the  Lung  and  of  the  Kidney. 
XVI — Cancer  of  the   (Esophagus.      Extension    into   the    Lung. 

Gangrene. 

XVII — Cancer  of  the  (Esophagus.     Pneumonia.     The   Pneumo- 
gastric Nerve  involved. 

XVIII — Cancer  of  the   (Esophagus.     The  left  Pneumogastric  in- 
volved.    Pneumonia. 

XIX — Cancer  of  the  (Esophagus.  Communication  with  the  Left 
Bronchus.  The  Pneumogastric  involved.  Old  Vomica 
in  the  Lung.  Extension  of  Disease  through  the  Dia- 
phragm. 

XX — Cancer  of  the  (Esophagus.  Pneumogastric  Nerves  trun- 
cated. Sloughing  extending  through  the  Lung  and 
through  the  Diaphragm. 

XXI — Medullary  Cancer  of  the  (Esophagus.  Chronic  Pneumonia. 
Vomica.  Acute  Pneumonia. 


540  ILLUSTRATIVE    CASES. 

CASK 

XXII Cancer  of  the  (Esophagus.     Artificial  opening  made  into 

the  Stomach. 

XXIII Cancer  of  the   (Esophagus.      Sloughing.      Perforation   of 

the  Aorta.     Sudden  and  Fatal  Hemorrhage. 

XXIV Aneurism  of  the  Aorta  and  Sloughing  (Esophagus. 

XXV. — Aneurism  of  the  Ascending  Aorta  rupturing  into  the  Peri- 
cardium. Communication  of  the  (Esophagus  with  the 
left  Bronchus. 

XXVI Aneurism.     Pressure  on  the  (Esophagus  and  on  the  left 

Bronchus.     Difficulty  in  Deglutition.     Sudden  Death. 
XXVII Dissecting  Aneurism  of  the  Aorta  bursting  into  the  (Eso- 
phagus. 

XXVIII Poisoning  by  Sulphuric  Acid. 

XXIX — Poisoning  by  Soap  Lees. 
XXX — Poisoning  by  Sulphuric  Acid. 
XXXI — Poisoning  by  Nitric  Acid. 
XXXII — Poisoning  by  Nitric  Acid.     Recovery  from  the  Primary 

Effects. 

XXXIII — Poisoning  by  Strong  Solution  of  Ammonia. 
XXXI V — Rupture  of  the  (Esophagus. 

XXXV — Syphilis.    Diphtheritic  Inflammation  of  the  Stomach.     Dis- 
eased Kidneys.     Necrosis  of  the  Bones  of  the  Nose. 
XXXVI — Suppuration  in  the  Coats  of  the  Stomach. 
XXXVII — Superficial  Ulceration  of  Stomach.     Diseased  Supra-renal 

Capsules. 
XXXVIII — Chorea.     Endocarditis  of  the  Mitral.     Ulceration  of  the 

Stomach. 
XXXIX — Catarrh  and  Superficial  Ulceration  of  the  Stomach.     Cystic 

Disease  of  the  Ovary. 
XL — Follicular   Ulceration    of  the   Mucous   Membrane   of  the 

Stomach,  with  Renal  Anasarca  and  Diseased  Heart. 
XLI — Follicular  Inflammation  of  the  Stomach.    Burn  on  the  Leg. 

Amputation.     Abscess  in  the  Lung  and  Spleen. 
XLII — Chronic   Ulcer  of  the  Stomach.     Phthisis.      Branches  of 

the  Pneumogastric  Nerves  involved. 

XLIII. — Chronic  Ulceration  of  the  Stomach,  involving  the  Pneumo- 
gastric Nerve.     Atrophy  of  the  Left  Lobe  of  the  Liver. 
Death  from  Exhaustion. 
XLIV — Chronic  Ulceration  of  the   Stomach,  with  Painter's  Colic. 

Perforation. 
XLV — Perforation.     Ulcer  of  the  Stomach,  with  a  second  small 

Chronic  Ulcer  in  the  same  organ. 

XLVI — Chronic  Ulceration.     Death  from  Perforation. 
XLVII — Chronic  Ulcer  of  the  Stomach.     Perforation. 
XLVIII — Perforating  Ulcer  of  the  Stomach. 
XLIX — Ulcer  of  the  Stomach.     Perforation. 

L — Chronic  Ulcer  of  the  Stomach.     Perforation  of  all  the  coats 

except  the  Peritoneal.     Fatal  Peritonitis. 
LI. — Perforation  of  the   Stomach.      Local   Suppuration  in   the 

Peritoneum.     Pleuro-pneumonia. 

LII — Chronic  Ulceration  of  the  Stomach,  extending  to  the  Dia- 
phragm, and  simulating  Pneumothorax. 

LIII — Fecal  Abscess,  connected  with  the  Stomach,  the  Lung,  the 
Spleen,  and  the  Transverse  Colon. 


ILLUSTRATIVE    CASES.  541 

CASE 

LIV — Chronic  Ulcer  of  the  Stomach.     Peritoneal  Abscess.     Per- 
foration of  the  Diaphragm.     Empyema. 

LV — Chronic  Ulceration  of  the  Stomach.  Perforation.  A  sinus 
extending  into  the  Left  Lung.  Gangrene.  Empyema. 
Second  Chronic  Ulcer. 

LVI — Chronic  Ulceration  of  the  Stomach.     Fatal  Hemorrhage. 
Perforation  of  the  Splenic  and  of  the  Pancreatic  Arteries. 
LVII — Ulceration  of  the  Stomach.     Fatal  hemorrhage. 
LVIII — Chronic   Ulceration,  with  Villous  Growth.  °  Stomach  ex- 
ceedingly contracted  simulating  Cancer. 
LIX — Chronic  Ulcer  of  the  Stomach. 
LX — Chronic  Ulcer  of  the  Stomach.     Relieved. 
LXI — Ulceration  (cancerous)  of  the  Stomach.     Relieved. 
LXII — Ulceration  of  the  Stomach.    Sloughing.    Paraplegia.     Soft- 
ening of  the  Spinal  Cord.     Disease  of  the  Vertebra. 
LXIII — Mottled  Kidney.    Anasarca,     Pneumonia.    Sloughing  mu- 
cous membrane  of  the  Stomach. 

LXIV — Thickened  Pylorus.     Cicatrix  of  the  mucous  membrane, 
with  hypertrophy.     Ulceration  of  the  Caecum  and  Colon. 
Fatty  Degeneration  of  the  Heart. 
LXV — Diseased  Pylorus.     Phthisis. 
LXVI — Scirrhous  Pylorus.     Carcinomatous  tubercles  in  the  Liver, 

Spleen,  and  Kidney,  and  on  the  Diaphragm. 

LXVII — Medullary  Cancer  of  the  Stomach,  having  a  villous  char- 
acter. 

LXVIII — Cancerous  disease  of  the  Stomach.  Exhaustion.  Epileptic 
Fit.  Coma.  Serous  subarachnoid  effusion.  Some  thick- 
ening of  the  Arachnoid. 

LXIX — Villous  Cancer  of  the  Stomach.  Perforation.  Extension 
into  the  Left  Lobe  of  the  Liver.  Secondary  opening  into 
the  Duodenum.  Death  from  sudden  Hemorrhage  into 
the  Stomach. 

LXX — Villous  Growth  of  the  Stomach.     Cirrhosis.     Ascites. 
LXXI — Colloid  Cancer  of  the  Stomach  and  of  the  Colon. 
LXXII — Colloid  Cancer  of  the  Stomach,  the  Omentum,  the  Perito- 
neum, and  of  the  Rectum. 

LXXIII — Chronic  Ulceration  of  the  Stomach.     Cancer. 
LXXIV. — Cancer  of  the  Stomach.     Communication  with  the  Colon. 
Ulceration  of  the  Caecum  and  Ileum.     Chronic  Phthisis. 
LXXV — Struma.     Cancer  of  the  Stomach. 

LXXVI — Cancer  of  the  Stomach.  Disease  of  the  Supra-renal  Cap- 
sule. 

LXXVII — Cancer  of  the  Pylorus,  simulating  Disease  of  the  (Eso- 
phagus.    Communication  with  the  Colon. 
LXXVIII — Cancer  of  the  Pylorus.     Hydatid  Disease  of  the  Cellular 

Tissue  of  the  Bladder. 

LXXIX — Haematemesis  from  Cancer  of  the  Liver. 
LXXX — Haematemesis  from  Portal  Congestion. 
LXXXI — Hsematemesis  after  great  Intemperance. 
LXXXII — Haematemesis.    Vicarious  Menstruation.    Aggravated  Hys- 
teria, simulating  Fever. 

LXXXIII — Vicarious  Menstruation  from  the  Stomach. 
LXXXIV. — Typhus  Fever.     Haematemesis. 


ILLUSTRATIVE    CASES. 
CASE 

LXXXV — Inflammation  of  the  Bronchi,  of  the  Bile-Ducts,  or  Biliary 
Hepatitis,  &c.     Acute  Congestion  of  the  Duodenum. 

LXXXVI Ulceration  of  the  Duodenum.     Perforation. 

LXXXVII. — Chronic  Ulcer  in  the  Duodenum.     Carcinoma  of  the  Liver. 
Jaundice.     Granular  Kidneys.     Obliteration  of  the  Bile- 
Duct. 
LXXXVIII — Strumous  Disease  of  the  Abdomen.     Perforating  Ulcer  of 

the  Duodenum  and  Caecum. 

LXXXIX. — Gall-Stone.  Ulceration  of  the  Gall-Bladder  and  Duodenum. 
Large  Gall-Stone  impacted  in  the  Jejunum.  Death  from 
Hemorrhage. 

XC — Cancer  of  the  Duodenum. 

XCI. — Chronic  Peritonitis.  Acute  Peritonitis.  Tubercular  de- 
position on  the  Serous  Membranes  and  in  the  Glands. 
Constriction  of  the  Duodenum,  and  great  Dilatation  of 
its  first  portion.  Small  Ulcer  in  the  Duodenum.  Large 
Chronic  Ulcer  in  the  Colon. 
XCII. — Obstruction  from  Biliary  Calculus  in  the  upper  part  of  the 

Jejunum,  thirty  inches  from  the  Pylorus. 
XCIII — Disease   of    the    Pancreas.     Suppuration    and    Gangrene. 

Pressure  on  the  Duodenum. 
XCIV. — Perforation  of   Duodenum  after  Death  from  Solution  by 

Gastric  Juice. 
XCV — Acute  Enteritis. 

XCVI — Enteritis  simulating  Mechanical  Obstruction. 
XCVII — Sloughing   Ileum.     Thrombosis  of  the  Mesenteric  Veins. 
Peritonitis.     Chronic  Tubal  Nephritis.     Lobular  Pneu- 
monia. 

XCVIII — Slight  Strumous  Disease  of  the  Mesenteric  Glands.     Diar- 
rhoea.    Pneumonia. 

XCIX — Strumous  Peritonitis.     Fecal  Abscess.     Artificial  Anus. 
C — Strumous  Disease  of  the  Mesenteric  Glands.     Obstruction 
of  the  Lacteals.     Ulceration  of  the   Small  and   Large 
Intestine.     Dysentery.     Phthisis. 
CI — Ulcerated  Colon.     Phthisis.     No  cough. 
CII — Phthisis.     Ulceration  of  the  Rectum  and  Sigmoid  Flexure. 
CIII — Unusually  free  Caecum. 
CIV — Unusually  free  Caecum. 
CV — Caecum  inverted. 

CVI — Intestinal  Obstruction  of  the  Ascending  Colon.    The  Caecum 
twisted  to  the  left  side  into  the  Left  Iliac  and  Hypochon- 
driac Regions.     Death  on  the  20th  day. 
CVII — Twisted  Caacum.     Obstruction.     Peritonitis. 
CVIII. — Cascal  Distension  and  Inflammation.     Typhlitis. 
CIX — Caecitis  or  Typhlitis. 
CX — Typhlitis. 

CXI — Caecal  Inflammation  simulating  Hip-joint  Disease. 
CXII — Caecal  Disease.     Typhlitis.     Recovery. 
CXIII — Strumous  Inflammation  of  the  Caecum. 
CXI  V — Perforation  of  the  Caecum.    Abscess  extending  to  the  Groin. 

Phthisis. 

CXV — Tuberculosis.  Ulceration  of  the  Intestine.  Ulceration  of 
the  Caecum.  Perforation.  Abscess  behind  the  ascend- 
ing Colon.  Old  Hydatid  in  the  Liver. 


ILLUSTRATIVE    CASES.  543 


CXVI — Inflammation  of  the  Colon  from  Plum  Stones.    Ulceration. 
Perforation.    Peritoneal  Abscess.    Thickening  and  Con- 
traction of  the  Bowel. 
CXVII — Phthisis.     Ulceration  of  the    Larynx    and  of  the  Ileum. 

Concretion  in  the  Appendix. 
CXVIII — Pyagmia.     Necrosed  Humerus.     Csecal  Disease.      . 

CXIX — Disease  of  the  Caecum  following  a  Blow.    Perforation  of  the 
Appendix.     Suppuration.     General  Peritonitis.    Almost 
complete  secondary  Perforation  of  the  Caecum. 
CXX — Local    Peritonitis.     Perforation  of  the   Appendix    Cseci. 

Strangulation  of  the  Ileum  by  the  Appendix. 

CXXI — Perforation  of  the  Appendix  Caeci.     Abscess  behind  the 
Ascending  Colon,  opening  into  the  Colon.     Clot  in  the 
Vena  Portae  and  Mesenteric  Vein.     Pyaamia. 
CXXII — Cancer  of  the  Caecum.     Abscess  in  the  Groin. 
C XXIII — Colloid  Cancer  of  the  Caecum.     Jaundice. 
CXXIV — Appendix  Caeci  in  the  Inguinal  Canal. 

CXXV — Inanition.     Diarrhoea. 
CXXVI — Chronic  Diarrhoea.     Hysteria.    Great  relief  from  Tincture 

of  Iron. 

CXX VII — Inflammation  of  the  Colon.     Diphtheria  of  the  Pharynx. 
CXXVIII — Diphtherite  of  the  Colon.     Dysentery.     Chorea. 
CXXIX — Inflammation  of  the  Colon.     Hernia. 
CXXX — Dysentery.      Ulceration  of  the    Small    Intestine.      Fecal 

Abscess.     Peritonitis. 

CXXXI — Ulceration  of  the   Large    Intestine.      Perforation.      Sub- 
mucous  Suppuration.     Pus  in  the  Portal  Vein,  and  In- 
flammatory Patches  in  the  Liver. 
CXX XI I — Dysentery.     Perforation  of  the  Colon. 

CXXXIII — Chronic   Bronchitic  Phthisis.     Cirrhosed  and  Lardaceous 
Liver.      Contracted   Abscess  of    the    Liver.      Chronic 
Dysentery,  and  Chronic  Peritonitis. 
C XXXIV — Chronic  Dysentery.     Hepatic  Abscess.    Pyaemia.    Abscess 

in  the  Brain  and  Lung. 
CXXXV — Dysentery.      Abscess  of  the    Liver.      Perforation   of  the 

Diaphragm.     Empyema. 

CXXXVI — Chronic  Ulceration  of  the  Intestine.  Dysentery.  Cicatri- 
zation. Contraction.  Perforation.  Abscess  near  the 
Crest  of  the  Ileum. 

CXXXVII — Dysentery.     Pneumonia.     Hydrencephaloid  Disease. 
CXXXVIII — Diphtherite  of  the  Caacum  and  Colon.    Bronchitis.    Pneu- 
monia.    Cirrhosis. 

CXXXIX — Inflammation  of  the  Colon  and  Rectum  with  False  Mem- 
brane and  superficial  Ulceration,  &c.  Pneumonia.  Ente- 
ric Fever  ? 

CXL — Fever.     Peritonitis. 

CXLI — Fever.     Perforation  of  Intestine  in  the  seventh  week. 
CXLII — Perforation  of  the  Ileum.     Typhoid  Fever. 
CXLIII — Internal  Strangulation  of  the  Ileum.     Band  of  Adhesion. 
CXLIV. — Internal  Strangulation.    A  Loop  of  Small  Intestine  passed 

into  a  hole  in  the  great  Omentum. 

CXLV — Internal  Strangulation  of  the  last  eighteen  inches  of  the 
Small  Intestine  by  means  of  a  Diverticulum  from  the 
ileum.  Fatal  after  thirty-eight  hours. 


r  •  • 

544  ILLUSTRATIVE    CASES. 

CASK 

CXLVI Internal  Strangulation  of  a  large  part  of  the  Small  Intes- 
tine. Death  on  the  fifth  day. 

CXLVII Internal  Strangulation.  Old  Peritoneal  adhesions.  Peri- 
tonitis. Suppuration. 

CXLVIII — Lead  Colic.  Internal  Strangulation  of  the  Intestine  from 
old  disease  of  a  Mesenteric  Gland,  and  subsequent  Fibroid 
Contraction. 

CXLIX. — Mechanical  Obstruction  terminating  favorably  after  seventy- 
eight  hours. 
CL. — Internal   Strangulation  and  Constipation.     Subsidence  of 

Symptoms.     Death  from  Phthisis. 
CLI. — Colic.     Simulation  of  Internal  Strangulation.     Recovery. 

CLII Colic.       Lumbrici.       Diarrhoea.       Intussusception    of   the 

Ileum  and  Ascending  Colon  into  the  Descending  Colon. 

CLI II Intussusception.     Recovery.      Caecum  and   whole    of  the 

Ascending  Colon  passed  per  Rectum. 

CLIV — Constipation.      Subsequent  perforation.     Peritonitis.     In- 
tussusception restored  ? 

CLV — Phthisis.     Intussusception  of  the  Ileum.     Peritonitis. 
CLVI — Intussusception  of  Ileum.     Perforation.     Peritonitis. 
CLVII — Intussusception  of  Sigmoid  Flexure.     External  Protrusion. 

Symptoms  of  Strangulation.     Peritonitis.      Death. 
CLVIII — Columnar  Epithelioma  of  the  Sigmoid  Flexure,  with  Can- 
cerous Infiltration  of  Glands  near  the  Gall-Bladder. 
CLIX — Cancer  of  the  Sigmoid  Flexure.     Perforation. 
CLX. — Cancerous  Disease  of  the  Sigmoid  Flexure.     Ecchymosis 
of    Stomach.      Ulceration   of  the   Ileum.      Contracted 
Mitral  Valve. 
CLXI — Cancer  of  the  Liver,  of  the  Lumbar  Glands,  and  of  the 

Sigmoid  Flexure. 
CLXII — Cancerous  Ulceration  of  the  Sigmoid  Flexure  of  the  Colon. 

Constipation. 
CLXIII — Cancer  of  the   Sigmoid  Flexure.     Obstruction  Relieved. 

Gradual  Exhaustion. 
CLXIV — Colloid  Cancer  of  the  Sigmoid  Flexure.     Artificial  Anus 

in  the  Groin.     Pleuro-pneumonia. 
CLXV — Cancerous   Disease  of  the   Sigmoid   Flexure.     Diarrhoea. 

Perforation.     Fecal  Abscess. 

CLX  VI — Cancerous  Disease  of  the  Rectum.     Old  Hernia. 
CLXVII — Cancerous    Disease    of    the    Transverse    Colon.       Fecal 

Abscess. 

CLXVIII — Carcinoma  of  the  Rectum,  of  the  Ovaries,  and  of  the  Peri- 
toneum. Acute  Peritonitis.  Scirrhus. 

CLXIX — Epithelioma  of  Rectum.  Contraction  and  Obstruction. 
Artificial  Anus  in  the  Loins.  Diseased  Appendix  Caeci. 
Fecal  Abscess. 

CLXX — Cancer  of  Jejunum,  and  of  the  Mesenteric  Glands.     Soften- 
ing of  the  Spinal  Cord.     Paraplegia. 
CLXXI. — Cancerous  Ulcer  of  the  Colon  opening  into  the  Duodenum. 

Diarrhoea.     Vomiting. 

CLXXII — Ulceration  of  the  Colon.     Intestinal  Obstruction  from  Con-  i 
traction  of  the  Transverse  Colon.     Cancer.     Dysentery. 
Constipation.     Diarrhoea. 


ILLUSTRATIVE    CASES.  545 

CASE 

CLXXIII.—Suppuration  external  to  the  Sigtnoid  Flexure  of  the  Colon 
opening  on  the  Anterior  Abdominal  Parietes,  and 
communicating  with  the  Intestine. 

Abscess  in  the  Loins.  Feculent  smelling  discharge 
Pleuro-pneumonia  with  Feculent  smelling  Sputum! 
Kecovery. 

*'--£Bceea  in  the  Loins-     Pleuro-pneumonia,     Recovery. 
L—Miscarnage.     Pyaemia.     Abscess  between  the  Uterus  and 
Bladder      Abscess  in  the  Loins,  opening   into  the  As- 
cendmg  Colon  and  into  the  Iliac  Vein. 
I.— Abscess  in  the  Hypogastric  Abdominal  Parietes  simulating 

Ovarian  Disease. 

CLXXVIIL—Suppuration  external  to  the  Right  Kidney.  Fibroid 
Ihickenmg  of  the  Tunic  of  the  Kidney.  Chronic  Pye- 
htis.  Obliteration  of  the  Vena  Cava.  Adhesion, 
thinning  and  doubtful  perforation  of  the  Ascending 
Colon. 

CLXXIX — Fecal  Abscess  in  the  pelvis,  communicating  with  the 
Ovary  and  Bladder,  opening  twice  into  the  Rectum  and 
on  the  Groin. 

CLXXX — Abscess  external  to  the  Rectum  leading  to  perforation. 
Considerable  fibrous  thickening,  and  Simulation  of  Can- 
cerous Disease. 

CLXXXI — Multilocular  Ovarian  Tumor.     Perforation  of  the  Caacum. 
Fecal    Abscess.       Pneumonia.       Pus    in    the    Ovarian 
Veins. 
CLXXXII — Ovarian  Tumor  filled  with  Feces  and  opening  into   the 

Ileum.     Pneumonic  Phthisis. 

[II — Extra-uterine  Fetation  opening  into  the  Sigmoid  Flexure. 
CLXXXI  V — Hypertrophy  of  the  Heart.     Adherent  Pericardium.    Acute 

Pericarditis.     Pleurisy  and  Peritonitis. 
.vLXXXV — Acute      Peritonitis.        Pericarditis.        Pleuro-pneumonia. 

Small  Granular  Kidneys. 

CLXXXVI — Peritonitis.     Local  Suppuration.     Perforation  of  the  Dia- 
phragm. 

CLXXXVII — Chronic   painless    Peritonitis.       Tubercle.       Great   Tym- 
panitis. 
CLXXX VIII — Ulceration  of  the  Intestine.     Strumous  Peritonitis.     Fecal 

Abscess.     Umbilical  Discharge. 
CLXXXIX — Peritoneal  Ascites.     Cancer  of  the  Ovaries  and  Peritoneum. 

Paracentesis.     Peritonitis. 

CXC — Carcinoma  of  the  Peritoneum  with  Effusion.      Paracen- 
tesis. 
CXCI — Chronic  Peritonitis.     Renal  Disease.     Spurious  Cysts  in 

the  Peritoneum. 
CXCII — Colloid  Cancer  of  the  Peritoneum  and  Ascending  Colon. 


35 


INDEX. 


4  BERCROMBIE,  disease  of  stomach,  18 
A    O3sophageal  stricture,  64 
muco-enteritis,  276 
diarrhoea,  360 
ileus,  425 

Abdominal  spaces,  530 
Abscess  in  parotid  gland,  37 
pharynx,  50 
tongue,  34 
tonsil,  42 

abdominal  parietes,  473-533 
in  the  iliac  fossa,  322 
Addison,  Dr.,  phantom  tumors,  530 

disease  of  supra-renal  capsule,  137 
\Adhesions  causing  strangulation,  421^423 
Albuniinuria,  dyspepsia  in,  218 

peritonitis  in,  504 
Alcohol,  use  of,  212-297 
cause  of  disease,  220 
poisoning  by,  126 
Alderson,  Sir  J.,  on  cancer,  73 
Amyloid  disease  of  stomach,  125 
Anaemia,  disease  of  spleen,  524 
Aneurism,  cause  of  dysphagia,  101 

hemorrhage  from  stomach,  233 
vomiting,  247 
diagnosis  of,  187 
causing  epigastric  pain,  244 
Aneurismal  tumor,  534,  536 
Angina  Ludovici,  48 
scrofulous,  50 
ulcerative,  50 

Annular  stricture  of  oesophagus,  68 
Annesley  on  dysentery,  360 
Anstie,  Dr.,  use  of  alcohol,  297 
Aphthae,  29 

Appendix  caeci,  atrophy,  318 
concretion,  318-319 
diseases  of,  312-315 
dilatation,  318 
increase  in  length,  318 
perforation  of,  320 
strangulation  by,  422 
tubercle  in,  290 
Ascaris  lumbricoides,  491 

vermicularis  or  oxyuris  vennicularis, 

492 
Ascites,  516 

varieties  of,  516 
symptoms  of,  517 
treatment,  528 
Asthenia  causing  dropsy,  518 


Atrophy  of  caecum,  315 

tongue,  26 

intestine,  278 

stomach,  115 

Auscultation  of  oesophagus,  72 
A  very,  Mr.,  obstruction  from  displacement 
of  caecum,  325 


BAKER,  Sir  G.,  on  lead  colic,  404 
Ballard,  Dr.,  on  pepsin,  214 
Ballingall  on  dysentery,  360 
Baly  on  dysentery,  360,  361,  362,  366 
Bamberger  on  dilatation  of  stomach,  120 
croupous  gastritis,  132 
phlegmonous  gastritis,  133 
Bands  causing  strangulation,  421,  425 
Barlow,  Dr.,  case  of  duodenal  disease,  271 
internal  strangulation,  421,  427, 

428 

Barker,  Dr.,  dilatation  of  oesophagus,  67 
Barthey  on  enteritis,  280 
Batters  by,  Dr.,  diagnosis  of  caecal  disease, 

322 

Bazin,  ichthyosis  of  the  tongue,  28 
Bean,  M.,  quinine  in  peritonitis,  509 
Beaumont,  Dr.,  observations  by,  18 
!  Bell,  Sir  C.,  oesophageal  pouch,  67 
!  Bennett,  Dr.  Hughes,  leucocythemia,  524 
Billing,  Dr.,  412 

Bird,  Dr.  Golding,  caecal  concretion,  319 
Birkett,  Mr.,  cancer  of  intestine,  432 
Bladder,  distension  of,  536 

perforation  by  disease  of  the  sigmoid 

flexure,  432-537 

Boudon  on  ipecacuanha  injection,  287-356 
I  Bougies  in  stricture  of  oesophagus,  64 
:  Brain  disease,  vomiting  in,  250 

diagnosis  of  enteritis,  285 
Brinton  on  cancer,  186 

follicular  gastritis,  138 
ulcer  of  stomach,  147 
ileo-colic  valve,  314 
intestinal  obstruction,  430 
Broadbent,  Dr.,  phosphorus  in  enlarged 

spleen,  524 

Broussais  on  enteritis,  276-279 
Brown,   Dr.    Blakeley,   case  of  duodenal 

obstruction.  274 
Bryant,  Mr.,  colotomy,  438 

on  opening  small  intestine,  438 
removal  of  spleen,  524 


548 


INDEX. 


Bucoal  psoriasis,  28 

Budd,  Dr.,  on  gastric  solution,  114-115 

dyspepsia,  217 

dysentery,  364 

gastric  fermentation,  231 
Bulbar  paralysis,  43     _• 
Bulimia,  229    ,*• 
Burns,  ulceration  of  duodenum,  255,  256 


pALCULI  in  appendix  caeci,  318 
\J     Cancrum  oris,  31—33 
Cancer  of  the  cjecum,  317,  322,  323 
duodenum,  265 
tonsil,  43 
pharynx,  51 
oesophagus,  72-73 
intestine,  423-431 
varieties  of,  432 
symptoms,  433 
diagnosis,  435 
treatment,  436 
(Jases  of,  455 
stomach,  182 

table  of  cases,  189 
treatment,  192 
diagnosis,  185-207 
cause  of  hemorrhage,  233 
Cancer  of  peritoneum,  496,  499,  505,  508, 

525 
Catarrh  al     inflammation      of      intestine, 

277-349 

colon,  276,  360-389 
stomach,  129 

Caustic  treatment  of  tonsillitis,  41 
Chambers,  Dr.  King,  pyrosis,  218 
Charcot,  vomiting,  255 
Children,  diarrhoea  in,  290 
Chouppe,  ipecacuanha  injection,  287-356 
Cicatrices  in  oesophagus,  71 
the  intestine,  363,  423 
Clark,  Dr.  Andrew,  catarrh  of  colon,  392 
Clarke,  Dr.  Fairlie,  on  buccal  psoriasis, 

28 

Clinical  Society,  case  by  Dr.  Gray,  271 
Cobbold,  Dr.,  on  entozoa,  487 
Caecum,  atrophy,  315 

cancer  of,  317,  322,  342 
changes  of  position,  325,  391 
congestion,  315 
cases  of  disease,  325 
diseases  of,  391 

disease  of,  causing  peritonitis,  502 
diagnosis  of  disease,  322 
distension  of,  315,  320,  321 
discoloration,  316 

inflammation  of,  typhlitis,  316,  321 
oedema,  315 

prognosis  in  disease,  323 
symptoms  of  disease,  320 
treatment,  324 

trichocephalus  dispar  in,  318 
tubercle  in  appendix,  290 
nlceration,  316 
Colic,  flatulent,  398 


Colic— 

from  lead,  painters',  405 

morbid  secretion,  402 

improper  food,  401 

spasmodic,  398 

causes  of,  399,  403 

diagnosis,  283,  399,  402 

treatment,  400,  402,  405 
Colon,  accumulation  in,  585 

diagnosis  of  disease,  188 

catarrh,  360,  389 

communication  with  stomach,  433 

distension  of,  408 

pouches  of,  408 

tumor  in,  532 

sigmoid  flexure,  ulceration,  537 
Colotoiny,  437 
Concretions  in  appendix,  318 

intestine,  419 

Congenital  defects  of  oesophagus,  69 
Constipation,  effects  of,  407 

causes,  409 

treatment,  415 

Contraction,  hour-glass,  of  stomach,  124 
Copland,  Dr.,  enteritis,  276 

oedema  of  legs  in  caecal  disease,  315 

on  colic,  398 
Corrosives,  stricture  of  oesophagus  from, 

106 
Corvisart,  pepsin,  214 

pancreatic  fluid,  253 

duodenal  dyspepsia,  253 
Crupous  gastritis,  132 
Cru'veilhier,  softening  of  stomach,  114 
Cunningham,  Dr.,  on  cholera,  350 
Curling,  Mr.  T.  B.,  ulceration  of  duode- 
num in  burns,  255 

on  colotomy,  438 
Cynanche  parotidea,  37 
Cysts  in  pharynx,  51 

in  oesophagus,  59 


DAVIES-COLLEY,  Mr.,  colotomy,  438 
deafness  from  tonsillitis,  41 
Diaphragm,  extension  of  oesophageal  can- 
cer to,  74 
Diarrhoea,  bilious,  347 

catarrhal,  348 

choleraic,  350 

cases  of,  358 

causes,  353 

diagnosis  of,  355 

dysenteric,  349 

inflammatory,  276 

prognosis  of,  354 

serous,  350 

in  strumous  disease,  289,  290 

varieties  of,  346 
Dickinson,    Dr.,    on    lardaceous    disea-.'. 

309 
Dilatation  of  oesophagus,  66 

of  stomach,  120 

in  cases  of,  122 
Diphtheria,  46 


INDEX. 


Diphtheritic  paralysis,  47 

statistics  of,  48 
Diphtheritic  membrane  in  oesophagus,  5 

inflammation  of  stomach,  131 
Distension  of  caecum,  315 
Diverticula  in  duodenum,  253 
causing  strangulation,  422 
Dix,  Mr.  J.,  case  of  disease  of  liver,  267 
Dropsy,  varieties  of  ascites,  516 

ovarian,  527 

Durham,  Mr.,  on  gastrotomy,  100,  101 
Duodenum,  anatomy  of,  252 
cancer  of,  265 
cases  of  disease,  259 
congenital  malformation,  253 
congestion,  254 
congestion,  chronic,  256 
diseases  of,  252 
distension  of,  253 
diverticuli,  253 
inflammation  of,  258 
obstruction  of,  268 
secretion  of,  253 
solution  of,  274 
table  of  cases,  265 
ulceration,  255,  258 
vomiting  in  diseases  of,  247 
Dysentery,  361 

morbid  anatomy,  361 
sequelae,  362,  363 
symptoms,  364 
causes,  366 
prognosis,  368 
pus  in  vena  portae,  380 
hepatic  abscess,  364 
contraction  of  colon,  385 
diagnosis,  368 
treatment,  369 
cases  of,  373 

with  pneumonia,  361,  386 
causing  perforation,  363,  379 
fecal  abscess,  363,  379 
cancer  of  colon,  363 
Dyspepsia,  varieties  of,  211 
atonic,  211 
climacteric,  214 
in  chronic  diseases,  214 
excessive   secretion  of  gastric   juice, 

216 

from  fermentation,  231 
from  impeded  movements,  229 
from  nervous  system,  222 
from  vascular  supply  altered,  220 
duodenal,  257 
in  phthisis,  21 
Dysphagia,  causes  of,  60 
from  diphtheria,  47,  55 
paralysis  of  soft  palate,  47 
suppuration  in  the  pharynx,  50 
spasmodic  stricture,  62,  65 
foreign  bodies,  110 
laryngeal  disease,  60 
paralysis  of  pharynx,  65 
in  mania,  62 
from  action  of  poisons,  106 


Dysphagia — 

disease  of  oesophagus,  56 
ulceration  of  oesophagus,  56 
syphilitic  disease,  69 
from  cicatrices,  71 

cancer,  72 

polypus,  101 

aneurism,  101 

tumors,  104 
in  pericarditis,  105 

ECCHYMOSIS  of  oesophagus,  110 
Embolism  of  gastric  vessels,  150 

as  a  cause  of  gastric  ulcer,  150 
Emphysema  of  the  mucous  membrane  of 

the  stomach,  117 

Empyema  from  ulcer  of  the  stomach,  164 
165 

abscess  of  the  liver,  384 
Enteric  fever,  393 
Enteritis,  276 

pathological  changes  in,  276 

symptoms,  279,  281 

diagnosis,  283  • 

cases  of,  281 

causes  of,  285 

prognosis,  286 

treatment,  286 

causing  intestinal  obstruction,  424 
Epithelioma  of  oesophagus,  74 
Eustachian  tube  in  parotitis,  37 

tonsillitis,  40 
Evanson,  diseases  of  children,  287 


FAGGE,    Dr.    Hilton,   on    dilatation    of 
stomach,  123 
suppurative  gastritis,  134 
on  lardaceous  disease,  310 
old  intussusception,  452 
peritoneal  diseases,  526 
gums  in  poisoning  by  lead,  32 
i'eces,  character  of,  352 
^"ecal  abscess,  with  perforation  of  stomach, 
.     163 

dysentery,  379 

disease  of  caecum,  333,  334,  335 
cancer  of  caecum,  342 
"ecal  abscess  with  cancer  of  colon,  463, 

464,  466 
with  suppuration  in  the  parietes 

of  the  abdomen,  475,  479 
from   ovarian  disease,  482,  484, 

485 

with  umbilical  discharge,  302 
'enwick,  Dr.,  on  the  stomach  in  scarla- 
tina, 27,  133 

'ermentation,  cause  of,  in  dyspepsia,  231 
'ever,  hemorrhage,  235,  395 

typhoid  disease  of  the  intestine,  393 
symptoms,  394 
treatment,  395 
cases  of,  396 
ibroid  disease  of  pylorus,  178 


35* 


550 


INDEX. 


Fistula,  gastric,  94 

Fletcher,  Mr.,  on  cesophageal  bougies,  80 

Follicular  gastritis,  138 

Foreign  bodies  in  oesophagus,  110 

stomach,  208 

duodenum,  268 

appendix  cseci,  318 

intestine,  424 

Forster,  Mr.,  gastrotomy,  94 
Fox,  Dr.  Wilson,  on  furred  tongue,  27 

gastric  catarrh,  130 

phosphorus    in  diseased  spleen, 

524 
Fraser,  Dr.,  on  green  vomit,  character  of, 

233 
Furred  tongue,  27 


pAIRDENER,    Dr.,     communication     of 
\J     stomach  and  colon,  433 
(rail-bladder,  enlargement  of,  532 
Gall-stone,  impaction  of,  262,  268,  424 
Gangrenous  stomatitis,  33 
Garrod,  Dr.,  blood  in  gout,  218 
Gastralgia,  224' 
Gastritis,  acute,  127,  241 

chronic,  129 

diphtheritic,  131 

with  scarlatina,  27 

phlegmonous,  133 
Gastric  ulcer,  139 

table  of,  144 

juice,  composition  of,  210 
disordered  states,  211 

solution,  111,  113 

of  duodenum,  274 
Gastrotomy,  76,  191 

table  of  cases,  100 
Gay,  Mr.,  constipation,  415 
Glands,  mesenteric,  disease  of,  293 

causing  obstruction,  423 
Glandular  ascites,  521 

disease  in  Hodgkin's  disease,  524 
Glossitis,  33,  36 

acute,  34 

subacute,  34 

Gmelin,  Dr.,  secretion  of  caecum,  314 
Goodhart,  Dr.,  on  lardaceous  disease,  310 
Goodsir  on  sarcina,  231 
Gorham,  Mr.,  discharges  in  intussuscep- 
tion, 284,  428 
Gordon,  report  on  diseases  in  India,  490 

treatment  of  tapeworm,  490 
Gout,  dyspepsia  in,  218 
Graves,  Dr.,  treatment  of  peritonitis,  506 

cerebral  vomiting,  249 
Gray,   Dr.   T.   6.,   case  of  impacted  gall 

stone,  271 

Gall,  Sir  Wm.,  on  dilatation  of  the  sto- 
mach, 123 

ulceration  of  duodenum,  255 

case  of  caecal  disease,  328 
fever,  394 

treatment  of  tapeworm,  490 

phantom  tumors,  530 


Gums  in  stomatitis,  32 

pigmented,  in  Addison's  disease,  32 
deposit  of  lead  in,  32 
in  phthisis,  226 


HALLIER,  on  cholera,  350 
Hamburger,  on  cosophageal  auscul- 
tation, 72 
Handfield  Jones,  on  atrophy  of  stomach, 

116 

Harley,  Dr.,  concretion  in  intestine,  419 
Harty,  Dr.,  on  dysentery,  368 
Headland,  Dr.,  on  the  action  of  medicines, 

21 

Heart,  dropsy  in  disease  of,  519 
Heidenheim,   on   the   influence   of  bella- 
donna upon  the  salivary  gland,  33 
Heller   on   intestinal   worms,   Ziemssen's 

Encycl.,  487 

Hernia,  diagnosis  of,  283 
Hesley,  Dr.,  treatment  of  peritonitis.  ">U7 
Hilcon,  Mr.,  on  atrophy  of  the  tongue,  26 
operation  in  internal  strangulation. 

437 
Hodgkin,   Dr.,  on   pathology  of  mucous 

and  serous  membranes,  258,  300 
disease  of  lymphatic  glands,  524 
Hsematemesis,  73,  233 
symptoms  of,  234 
diagnosis,  236 
treatment,  236 
cases  of,  237 

from  ulceration  from  gall-stone,  262 
Hemorrhage  in  gastric  ulcer,  141 

in  fever,  395 
Hemorrhagic  erosion,  134 
Hemorrhoids,  diagnosis  of  dysentery,  368 

causing  obstruction,  424 
Hourglass  contraction  of  stomach,  124 
Howse,  Mr., operation  in  intussusception, 

439 
Hulke  on  ichthyosis  of  the  tongue,  28 

on  oesophagismus,  65 

Hunter,  Mr.  John,  on  gastric  solution,  114 
Hutchinson,   Mr.  Jonathan,  on  the  dys- 
pepsia of  phthisis,  21 
operation  in  internal  strangulation, 

439 

in  intussusception,  453 
case  of,  439 
Hydatid  obstruction  of  duodenum,  268,274 

tumors,  532,  534-536 
Hydatids,  488 
Hypertrophy  of  oesophagus,  66 

of  stomach,  119 
Hysteria,  diagnosis  of  enteritis,  284 


TCHTHYOSIS  of  the  tongue,  28 
1     Ileo-colic  valve,  314 
Ileum,  disease  of,  simulating  caecal  dis- 
ease, 322 
Ileus,  425 
Inflammation  of  caecum,  316 


INDEX. 


551 


Inhalation  in  tonsillitis,  42 

Internal  strangulation,   state   of  rectum 

428 

symptoms  of,  429 
cases  of,  439 

Intestine,  disease  of,  in  phthisis,  302 
Intestinal  obstruction,  relative  frequency 

548 

strangulation,  425 
symptoms  of,  425 
worms,  487 

symptoms  of,  tapeworm,  489 
round  worm,  492 
thread  worms,  492 
treatment  of  tapeworm,  490 
of  round  worm,  492 
of  thread  worm,  493 
varieties  of,  487 
tumors,  530,  532 

Intestine,  cancerous  disease  of,  431 
perforation  from  without,  473 
Intussusception,    diagnosis    of    enteritis 

284,  423,  429,  535 
symptoms  of,  431 
causes  of,  and  prognosis,  431 
treatment  of,  438 


TENNER,    Sir  W.,  on  use  of  hyposul 
tl          phites,  231 

typhoid  intestine,  393 
Jones,  Dr.  Handfleld,  pyrosis,  217 

KENNEDY,   Dr.,    hemorrhage   without 
ulceration,  235 
Kidneys,  disease  of,  cause  of  dropsy,  521, 

523 

diagnosis  of  enteritis,  285 
tumors,  532,  534,  535 
loose,  530 
suppuration,  diagnosis  of,  caecal  dis- 
ease, 322 

King,  Mr.  Wilkinson,  on  gastric  solution, 
111 


LABIO-GLOSSO-LARYNGEAL  paralysis, 
43 

Lactic-acid  fermentation,  dyspepsia,  232 
Lardaceous  disease  of  stomach,  125,  289, 

308 

pathological  changes,  309 
symptoms,  310 
prognosis,  310 
table  of  relative  frequency  in  viscera, 

311 

Laryngeal  dysphagia,  60 
Latham  on  dysentery,  360 
Lead  colic,  404 

Lebert  on  ulceration  of  stomach,  148 
Leudet,  perforation  of  caecum,  317 
Letzerich  on  diphtheria,  48 
Lewis,  Dr.,  on  cholera  spores,  350 


J.i<mviUe,-hemorrhage  into  rectum,  2'!5 
Liver,   diagnosis    of    cancer  of  stomach, 
187 

disease  of,  causing  dropsy,  519,  521 

tumors  of,  531 

cirrhosis,  521,  527,  528 

displacement  of,  531 

enlargement  of,  532 
Ludovici  angina,  48 
Lungs  affected  in  tonsillitis,  41 

affection  in  cancer  of  oesophagus,  78 
Lyon,  Dr.,  Crimean  report,  361 

VfAINGAULT  on  diphtheria,  47 
ill     Malformation  of  oesophagus,  69 
Maramillation  of  stomach,  119 
Marcet,  Dr.,-  foreign  bodies  in,  419 

lardaceous  disease,  309 
Marsh,  Sir  Henry,  irritability  of  stomach, 

226,  250 
Maunder,  Mr.,  colotomy,  438 

operation  of  opening  small  intestine, 

438 

Maunsell,  on  diseases  of  children,  287 
Mayne,  Dr.,  dysentery,  364 
Mayo  on  cesophageal  stricture,  64 
Mediastinal  tumors,  104 
Medical  Gazette,  case  of  intussusception, 

452,  453 
Melsena,  351 

Membranous  pharyngitis,  46 
Menstruation,  vicarious,  233 
Mercurial  stomatitis,  32 
Mesenteric  disease  of  glands,  290,  293 
symptoms,  294 
diagnosis,  295 
prognosis,  296 
causes,  296 
cases  of,  306 
Mesentery,  contraction  of,  517 

tumors  in,  535 
Metastasis  in  parotitis,  37 
McGrigor  on  dysentery,  360 
Moore,  Charles  H.,  use  of  injection  in  diag- 
nosis of  strangulation,  428 
tforehead  on  dysentery,  360,  362,  366 
Morris,  Mr.  Henry,  on  ichthyosis  of  the 

tongue,  28 
Moxon,  Dr.,  on  phlegmonous  gastritis,  134 

lardaceous  disease,  309 
tfuguet,  30 
Muco-enteritis,  276 
cases  of,  281 
see  Enteritis, 
[ucous  membranes,  wasting  of  stomach, 

115 

wasting  of  intestine,  279 
tubercle,  290 
'urchison,    Dr.,    hemorrhage    in   enteric- 
fever,  395 
on  stomach,  146 

communication  of  stomach  and  colon, 
433 


552 


so 


INDEX. 


1  YjBRYors  rlyspli.-i-ia,  03 
IN          dvspopsia,  226 

dinrrhoja,  350 
Neuralgia  of  the  tongue,  36 


ABSTRACTION  of  duodenum,  268 
\J        organic,  of  intestine,  421 

varieties,  421 

symptoms,  425 

Odling,  Dr.,  csecal  concretion,  319 
(Edema  of  caecum,  315 
(Esophagisinus,  65 
(Esophagus,  diseases  of,  53 

anatomy  of,  53 

acute  inflammation,  54 

ulceration  of,  56 

abscess,  59 

cysts,  59 

warts,  59 

spasmodic  stricture,  63 

paralysis  of,  65 

hypertrophy  of,  66 

dilatation  of,  66 

pressure  upon  by  tumors,  68 

strictures,  69 

congenital  defects,  69 

action  of  poisons,  105 

cicatrices,  71 

cancer  of,  72 

causes  of  death  in  cancer  of,  75 

tables  of,  76 

statistics  of,  77 

affections  of  the  lung  in,  78 

polypi,  101 

myoma  of,  101 

hemorrhage  from,  233 

obstruction  in  aneurism,  101 

foreign  bodies  in,  110 

ecchymosis  of,  110 

rupture  of,  111 

solution  of,  111 
Omentum,  diagnosis  of  disease,  187 

tumor  in,  533-535 

Oppolzer  on  phlegmonous  gastritis,  134 
Osborne,  Dr.,  pain  in  gastric  ulcer,  243 
Ovary,  disease  of,  producing  dropsy,  517, 
527 

disease  of  with  ascites,  518 

tumors,  534,  535,  536,  537 

diagnosis  of  caecal  disease,  322 


PAGET,  Sir  James,  on  atrophy  of  tongue, 
26 

psoriasis  of  the  tongue,  28 

ringworm,  36 
Pain  in  disease  of  stomach,  224 

as  a  symptom,  causes  of,  240 

in  internal  strangulation,  426 
Pancreas,  diagnosis  of  disease,  187 

causing  obstruction,  268,  271,  272 

tumor,  532,  533 

Panum  on  circulation  in  the  stomach,  149 
Paralysis  of  the  tongue,  26 


Paralysis — 

soft  palate,  43 

stomach,  121 

Parkes,  Dr.,  on  dysentery,  360 
Parotitis,  37 

Parietes,  abdominal,  suppuration  in,  473, 
474,  533 

diagnosis  of,  treatment,  475 

cases  of,  475 
Pathological  transactions — 

caecum    displaced,    obstruction,    Mr. 
Abery,  325 

cancer  of  intestine,  Mr.  Birkett,  432 

case  of  intussusception,  J.  Hutchin- 
son,  453 

case  of  hsematemesis,  261 

foreign  bodies  in  appendix  caeci,  318 

case  of  constipation,  Mr.  Gay,  415 

concretion  in  intestine,  419 
Pavy,  Dr.,  on  gastric  solution,  113,  149 
Perforation  of  trachea  in  cancer  of  oeso- 
phagus, 81 

Pericarditis,  dysphagia  in,  105 
Peristaltic  movements,  426 
Peritoneum,    adhesions   causing   obstruc- 
tion of  duodenum,  268 

tubercle  of,  290,  296,  297 

loose  bodies  in,  515 
Peritonitis,  pathology  of,  varieties,  495 

symptoms,  497 

diagnosis,  499 

prognosis,  284,  500 

causes,  529 

treatment,  505 

cases,  504,  509 

causing  obstruction,  424 

chronic,  496,  507 

tubercular,  496,  499,  504,  525 

cancerous,  496,  499,   505,   508,   525, 
527 

in  cirrhosis,  505,  508 

in  albuminuria,  504,  507 

puerperal,  504,  507 

strumous  and  tubercular,  297 

cause  of  dropsy,  520 
Pharynx,  anatomy  of,  45 

spasm,  45 

inflammation,  45 

chronic,  46 

follicular,  46 

membranous,  46 

phlegmonous,  48 

syphilitic,  49 

cancer,  50,  51 

suppuration  behind,  50 

cysts  in,  51 
Philip,  Dr.  Wilson,  experiments  of,  21 

distension  of  stomach,  230 
Phillips,  Mr.  Benjamin,  case  of  intussus- 
ception, 452 

Phlegmonous  gastritis,  133 
Phthisis,  dyspepsia  in,  21 

disease  of  intestine,  302 

stomatitis,  32 

gums,  226 


INDEX. 


553 


Phthisis- 
irritability  of  stomach,  251 
Pleuritic  effusion  simulating  enlargement 

of  liver,  531 

Pneumogastric,  influence  on  stomach,  21 
Pneumonia  in  cesophageal  cancer,  74 
Poisons,  effect  of,  106 
Poisoning,  diagnosis  of,  125 

enteritis,  284 

Poland,  Mr.,  on  cancer  of  tonsil,  43 
Polypus  in  oesophagus,  101 

intestine,  423 

Polypi  in  stomach,  139,  181 
Post-mortem  solution  of  stomach,  113 
Pouches,  pharynx,  51 

oesophagus,  67 

Pringle,  Sir  J.,  use  of  ipecacuanha,  370 
Prout,  Dr.,  dyspepsia,  218 

concretion  in  appendix,  319 
Pulse,  depression  of,  in  abdominal  disease 

20 

Pulsation,  abdominal,  533 
Pylorus,  fibroid  disease  of,  178 
cancer  of,  182 


QUININE  in  cancrum  oris,  33 
Quinsy,  38,  39 


EECTUM,  disease  of,  diagnosis  of  dysen- 
tery, 368 

polypus,  368 

fibro-cellular  ulceration,  368 

state  of  sphincter,  369 

impacted  feces,  369 

state   of,    in   internal   strangulation, 
429 

disease  of,  causing  peritonitis,  503 
Rheumatism,  dyspepsia,  218 
Rilliet  on  enteritis,  280 
Rindfleisch  on  aphthae,  30 
Ringworm  of  the  tongue,  36 
Rokitansky  on  gastric  ulcer,  149 

displacement  of  caecum,  312 

dysentery,  361 

typhoid  intestine,  393 
Roper,  Dr.,  ileo-colic  valve,  314 
Rupture  of  oesophagus,  111 

S ALTER,  Dr.    Hyde,    on   tracheal    dys- 
phagia,  61 
Saiidvvith,  Dr.,  perforation  of  intestine  by 

lumbrici,  491 
Scarlatinal  gastritis,  133 
Schmidt,    composition    of    gastric    iuice, 

216 

hemorrhage  from  oesophagus,  233 
Scrofulous  angina,  50 
Siebold,  Von,  treatise  on  entozoa,  487 
Solution  of  oesophagus,  111 
of  stomach,  112-113 
of  duodenum,  274 
South ey,  Dr.,  drainage  tubes,  507 


Spasm  of  tongue,  36 

of  pharynx,  45 

of  oesophagus,  63 
Spinal  disease,  535 
Spleen,  disease  of,  causing  ascites,  521, 

removal  of,  by  Mr.  Bryant,  524 
tumors  of,  534 
Staniland,  constipation,  415 
Steffen,  on  oesophageal  disease  in  children 

55 
Stewart,   Dr.  Grainger,  gastric  crises  in 

locomotor  ataxia,  225 

Stewart,  Dr.  A.  P.,  on  typhoid  fever,  393 
btokes,  Dr.,  treatment  of  peritonitis,  506 
Stomach,  solution  of,  113 
atrophy  of,  115 
hypertrophy  of,  119 
polypi  in,  119,  219 
mammillation  of,  120 
dilatation  of,  120 
hour-glass  contraction,  124 
lardaceous  disease,  125 
effects  of  poisons,  125 
acute  gastritis,  127 
chronic,  129 
diphtheritic,  131 
suppurative,  133 
suppuration  in  coats  of,  133 
ulceration  of,  134 
hemorrhagic  erosion,  134 
hemorrhage,  233 
follicular  ulceration,  138 
perforating  ulcer,  140 
table  of  cases  of  ulcer,  144 
causes  of  ulceration,  149 
symptoms,  150 
causes  of  death  in  ulcer,  153 
treatment  of  ulceration,  171 
sloughing  of,  176 
tumors  of,  533 

fibroid  disease  of  pylorus,  1 78 
cancer  of,  182 
diagnosis  of  cancer  of,  185 
statistics  of  cancer  of,  186 
treatment  of  cancer,  192 
foreign  bodies  in,  253,  419 
Stomatitis,  29 

treatment  of,  29 
follicular  affection  in,  29 
ulcerative,  31 
phthisical,  32 
scorbutic,  32 
mercurial,  32 
gangrenous,  33 
syphilitic,  36 
Strumous   disease    of   alimentary  canal, 

289 

peritoneum,  297,  496 
symptoms,  300 
causes,  301 
treatment,  301 
intestine,  535 

Strangulation  of  intestine,  421,  425 
from  bands  of  adhesion,  431 


554 


INDEX. 


Suppuration  behind  pharynx,  50 

in  abdominal  parietes,  473,  533,  534 
diagnosis  of  caeca!  disease,  322 

Syphilitic  ulceration  of  tongue,  36 
pharyngitis,  49 
stricture  of  oesophagus,  69 

Supra-reiial  capsule,  tumor  of,  532,  533, 
534 


TABLE  of  cases  of  cancer  of  ossophagus, 
76 

gastrotomy,  100 
ulcer  of  stomach,  144 
cancer  of  stomach,  189 
dysentery,  373 
Taylor,  Dr.,  on  poisons,  402 
Teeth,  carious,  a  cause  of  ulceration  of  the 

tongue,  35 
Thompson,  Dr.  T.,  on  the  gums  in  phthisis, 

32,  226 

on  injections  in  phthisis,  306 
Thrush,  30 
Tiedemann  on  the  secretion  of  the  caecum, 

314 

Tongue  wasting,  and  paralysis,  26,  27 
anaemic,  27 
livperaemic,  27 
furred,  27 
warty,  28 
ichthyosis  of,  28 
in  stomatitis,  29 
inflammation  of,  33,  35 
abscess  of,  35 

treatment  of  acute  inflammation,  34 
chronic  inflammation,  34 
treatment  of,  35 
ulcerated,  in  phthisis,  35 

from  carious  teeth,  35 
syphilitic  ulceration  of,  36 
neuralgia  of,  36 
spasm  of,  36 
ringworm  of,  36 
Tonsil,  38 

structure  of,  38 
ulceration  of,  38-40 
acute  catarrh  of,  39 
erysipelatous  inflammation  of,  40 
cancer  of,  43 
suppuration  of,  39 
syphilitic  ulceration  of,  40 
strumous  disease  of,  40 
chronic  hypertrophy  of,  40 
excision  of,  42 

Tracheotomy  in  acute  tonsillitis,  42 
Tracheal  dysphagia,  60 
Travers,  case  of  perforation  of  duodenum, 

260 

Trichocephalus  dispar,  492 
in  caecum,  318 


Trousseau,  injection  of  nitrate  of  silver, 

358,  371 

Tubercular  disease  of  alimentary  canal,  289 
of  peritoneum,  297 
of  intestine,  302,  394 
Tumors,  abdominal,  530 

phantom,  530 

varieties  of,  531 

causing  obstruction,  423 
Turnbull,  Dr.,  on  fermentation,  22 
Turpentine  in  tonsillitis,  41 
Twining,  use  of  ipecacuanha,  370 
Twist  of  caecum,  312 

bowels,  423 

Tympanitis  in  obstruction,  426 
Typhlitis,  316 
Typhus,  parotitis  in,  37 
Typhoid  disease  of  intestine,  393 


TTLCERATION  of  stomach,  134 

U         follicular,  138 

Ulcers  of  stomach,  causes  of,  149 
symptoms  of,  150 
causes  of  death  in,  153 
treatment  of,  171 
of  duodenum,  255,  258 
of  intestine  in  enteritis,  278 
of  colon  in  dysentery,  362,  363 
in  phthisis,  302 
of  caecum,  316 

Urine,  quantity  of,  in  internal  strangula- 
tion, 427 

Uterus,  enlargements  of,  536 

Uvula,  excision  of,  42 


TTERNEUIL'S  case  of  gastrotomy,  101 
«      Virchow  on  parotitis,  37 
'Archiv',  32,  51 
on  amyloid  disease,  309 
Vomiting  in  gastric  ulcer,  173 
dyspepsia,  224 
as  a  sign  of  disease,  240,  244 
in  internal  obstruction,  427 


WARD,  Mr.  N.,  foreign  bodies  in  appen- 
dix caeci,  319 

Warty  tumors  of  pharynx,  51 
Weisse,  Dr.,  use  of  raw  meat,  291 
West,  Dr.,  on  diarrhrea,  276 

muco-enteritis,  280 

Wilks,  Dr.,  ulceration  of  duodenum,  255 
cancer  disease  on  dysenteric  cicatrix, 
363 


YOUNG,  Dr.,  lurnbrici  passing  through 
abdominal  parietes,  491 


WORKS  BY  AUSTIN  FLINT,  M.D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  N.  Y. 


A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE  OF  MEDICINE- 

DESIGNED  FOR  THE  USE  OP  STUDENTS  AND  PRACTITIONERS  OF  MEDICINE. 
Fourth  Edition,  Revised  and  Enlarged. 

In  one  large  and  clot  ly  printed  octavo  volume  of  nearly  1)00  pages  :  cloth,  $6  :  or  strongly 
bound  in  leather.,  with  raised  bands,  $7.      (Lately  Issued.) 


This  excellent  treatise  on  medicine  has  acquired 
for  itself  in  the  United  States  a  reputation  similar  to 
that  enjoyed  in  England  by  the  admirable  lectures  of 
Sir  Thomas  Watson.  It  may  not  possess  the  same 
charm  of  style,  but  it  has  like  solidity,  the  fruit  of 
long  and  patient  observation,  and  presents  kindred 
moderation  and  eclecticism.  We  have  referred  to 
many  of  the  mostimportant  chapters,  and  find  there- 
vision  spoken  of  in  the  preface  is  a  genuine  one,  and 
that  the  author  has  very  fairly  brought  up  his  matter 
to  the  level  ofthe  knowledge  of  the  present  day.  The 
work  hat.  this  great,  recommendation,  that  it  is  in  one 
volume,  and  therefore  will  not  be  so  terrifying  to  the 
student  as  the  bulky  volumes  which  several  of  our 
English  text-books  of  medicine  have  developed  into 
—British  and  For.  Med.-Ghir.  Rev.,  Jan.  1875. 

It  is  of  course  unnecessary  tointroduce  or  eulogize 
this  now  standard  treatise.  All  the  colleges  recom- 
mend it  as  a  text-book,  and  there  are  few  libraries 
in  which  one  of  its  editions  is  not  to  be  found.  The 
present  edition  has  be«n  enlarged  and  revised  to 
bring  it  up  to  the  author's  present  level  of  experience 
and  reading.  His  own  clinical  studies  and  the  latest 
contributions  to  medical  literature  both  in  this  coun- 


try and  in  Europe,  have  received  careful  attention 
so  that  some  portions  have  been  entirely  rewritten ' 
and  about  seventy  pages  of  new  matter  have  been 
added.  —  Chicago  Med.  Jo'i-rn.,  June,  187.3 

Has  never  been  surpassed  as  a  text-book  for  stu- 
dent' and  a  book  of  ready  reference  for  practitioners 
The  force  of  its  logic,  its  simple  and  practical  teach- 
ings, have  left  it  without  a  rival  in  the  fleld  — ff  Y 
Med.  Record,  Sept.  15,  1874. 

Prof.  Flint,  in  the  fourth  edition  of  his  great  work, 
has  performed  a  labor  reflecting  much  credit  upon 
himself,  and  conferring  a  lasting  beneBt  upon  the 
profession  The  whole  work  shows  evidence  of  tho- 
rough revision,  so  that  it  appears  like  a  new  hook 
written  expressly  for  the  times.  For  the  general 
practitioner  and  student  of  medicine,  we  cannot  re- 
commend the  book  in  too  strong  terms.— 2f  Y  Med 
Jmi.rn.,  Sept.  1873. 

It  is  given  to  very  few  men  to  tread  in  the  steps  of 
Austin  Flint,  whose  single  volume  on  medicine 
though  here  and  there  defective,  is  a  masterpiece  of 
lucid  condensation  and  if  general  grasp  of  an  enor- 
mously wide  subject.— Land.  Practitioner,  Dec.  '73. 


PHTHISIS  — ITS  MORBID  ANATOMY,  SYMPTOMATIC  EVENTS  AND 
n?faMF^TIONS'  FATALITY  AND  PROGNOSIS,  TREATMENT  AND  PHYSICAL 
DIAGNOSIS,  IN  A  SERIES  OP  CLINICAL  STUDIES.  In  one  large  and  handsome  octavo  vol- 
ume of  446  pages  :  cloth,  $3  50. 


III. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORATION  OF  THE 
CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE  RESPIRATORY 
ORGANS.  Second  and  Revised  Edition.  In  one  handsome  octavo  volume  of  595  pages: 
cloth,  $4  50. 


IV. 
A  PRACTICAL  TREATISE  ON  THE   DIAGNOSIS.  PATHOLOGY    AND 

TREATMENT  OF  DISEASES  OF  THE  HEART.     Second  Revised  and  Enlarged  Edition 
In  one  octavo  volume  of  550  pages,  with  a  plate:  cloth,  $4. 


V. 

A  MANUAL  OP  PERCUSSION  AND  AUSCULTATION-  OP  THE  PHY- 
SICAL  DIAGNOSIS  OF  DISEASES  OF  THE  LUNGS  AND  HEART,  AND  OF  THO- 
RACIC ANEURISM.  In  one  handsome  royal  12mo.  volume  of  255  pages:  cloth,  $1  75. 


VI. 

CLINICAL  MEDICINE.  A  SYSTEMATIC  TREATISE  ON  THE  DTAG- 
NOSIS  AND  TREATMENT  OF  DISEASES.  DESIGNED  FOR  STUDENTS  AND  PRAC- 
TITIQJSIERS  OF  MEDICINE.  In  one  large  and  handsome  octavo  volume.  (Shortly.) 


HENRY  C.  LEA— Philadelphia. 


WORKS  ON  PRACTICAL,  MEDICINE. 


BRISTOWE'S  PRACTICE— Just  Issued. 
A  TREATISE  ON  THE  THEORY  AND   PRACTICE   OP  MEDICINE.     By 

JOHN  SYER  BRISTOWE,  M.D.,  F.R  C.P.,  Physician  and  Joint  Lecturer  on  Medicine,  St. 
Thomas's  Hospital.  Edited,  with  Additions,  by  JAMES  H.  HUTCHINSON,  M.D..  Physician 
to  the  Pennsylvania  Hospital.  In  one  large  and  handsome  octavo  volume  of  1089  closely 
printed  pages,-  cloth,  $5  50;  sheep,  $6  50. 


This  portly  volume  is  a  marvel  of  condensation. 
In  a  style  at  once  clear,  interesting,  and  concise,  Dr. 
Bristowe  passes  in  review  every  conceivable  subject 
connected  with  the  practice  of  medicine.  Those 
practitioners  who  purchase  few  books  will  find  this 
a  most  opportune  publication,  because  so  miny  top- 
ics not  usually  embraced  in  a  work  on  practice  are 
adequately  handled.  The  book  is  a  thoroughly  go  >d 
one,  and  its  usefulness  to  American  readers  has  been 
increased  by  the  judicious  notes  of  the  Editor. — 
Cincinnati  Clinic,  Jan.  7,  1877. 


Upon  the  whole,  we  know  of  no  work  which  we 
could  more  confidently  recommend  to  the  student  or 
the  practitioner,  intending  a  review  of  the  field  of 
theory  and  practice,  than  this  book  of  Dr.  Bris- 
towe's.  We  thus  commend  it,  because  the  vast  ar- 
ray of  facts  pertaining  to  the  practice  of  medicine,  as 
it  is  to-day,  are  here  presented  ably,  and  with  that 
method,  order,  and  perspicuity  which,  in  all  depart- 
ments of  education,  distinguish  the  lessons  of  an  ac- 
ceptable and  profitable  teacher.  —  Chicago  Afed. 
Journ.  and  Examiner,  Aog.  1877. 


FOTHERGILL'S  HANDBOOK  OF  TREATMENT— Just  Issued. 


TBE  PRACTITIONER'S  HANDBOOK  OP  TREATMENT:  OR.  THE  PRIN- 
CIPLES OP  THERAPEUTICS  By  J.  MILNER  FOTHERGILL,  M.D.  Assistant  Physician  to  the 
Hospital  for  Diseases  of  the  Chest,  to  the  West  London  Hospital,  etc.  etc.  In  one  very 
neat  octavo  volume  of  about  575  pages  :  cloth,  $4. 

None  can  read  it  without  being  impressed  with  the  |  fundamental  principles  of  medicine  in  such  away 
Immense  amount  of  common  sense  which  is  possessed  as  to  give  them  a  practical  application  to  treatment. 
by  the  author,  as  well  as  natural  tact  in  interpreting  It  is,  in  fact,  one  of  the  most  interesting,  entertaining, 
the  indications  of  treatment.  His  style  is  clear  and  and  instructive  works  of  its  kind  that  we  have  ever 
agreeable,  and  he  has  the  faculty  of  expounding  the  i  read. — Med.  Record,  March  17,  1S77. 


FOX  ON  DISEASES  OF  THE  SKIN— New  Edition— Just  Ready. 

EPITOME  OP  SKIN  DISEASES,  WITH  FORMULAE.     For  Students  and  Prac- 
titioners.    By  TILBURY  Fox,  M.D. ,  F.B.C.P.,  Physician  to  Department  of  Skin  Diseases, 
Univ.  Hospital  College,  London,  and  T.  C.  Fox,  B.A.,  M.R.C.S.     Second  edition.     Tho 
roughly  revised  and  greatly  enlarged.     In  one  very  handsome  12mo.  volume  of  216  pages. 
Cloth,  $1  38. 

PREFACE. 

"In  preparing  this  edition  of  our  'EPITOME'  for  publication  in  the  United  States,  we  have 
increased  the  matter  to  about  three  times  its  original  amount.  The  kindly  appreciation  mani- 
fested for  the  work  by  the  American  profession  has  stimulated  us  to  spare  no  pains  in  rendering 
it  more  worthy  of  their  approbation,  and  in  its  enlarged  form  we  believe  that  it  will  be  found  of 
enhanced  value.  About  two  thirds  of  the  work  is  newly  written,  and  we  may  direct  attention 
particularly  to  the  section  regarding  the  Pathology  of  the  Skin,  which  has  been  entirely  recast, 
and  now  contains  a  concise  account  of  all  the  important  changes  taking  place  in  the  dermal 
textures  in  disease.  The  clinical  descriptions  of  diseases  also  have  been  amplified  and  occasion 
ally  remodelled.  Lastly,  we  may  say  that,  in  adding  material  to  the  book  we  have  selected 
such  as  bears  on  the  practical  side  of  Dermatology,  to  the  exclusion  of  that  which  is  as  yet 
hypothetical  or  merely  of  interest  to  the  curious  student. 

"The  favorable  reception  accorded  to  the  work  on  both  sides  of  the  Atlantic  would  seem  to 
show  that  it  has  realized  the  object  with  which  it  was  prepared — to  afford  assistance  to  the 
student  in  his  early  study  of  dermatology,  and  to  serve  as  a  manual  for  ready  reference  by 
the  practitioner  in  his  daily  practice.  For  this  latter  purpose  it  has  been  specially  adapted,  by 
means  of  the  references  made  in  the  sections  on  treatment  to  the  formulae  at  the  end." 


HAMILTON  ON  NERVOUS  DISEASES— Now  Ready. 

NERVOUS  DISEASES;  THEIR  DESCRIPTION  AND  TREATMENT.     By 

ALLAN  McLANE  HAMILTON,  M.D  ,  Attending  Physician  to  the  Hospital  for  Epileptics  and 
Paralytics,  Blackwell's  Island,  N.  Y.,  and  to  the  Out-Patients'  Department  of  the  New 
York  Hospital.  In  one  handsome  octavo  volume  of  512  pages,  with  63  illustrations; 
cloth,  $3  50 


This  is  unquestionably  the  best  and  most  complete 
text-book  of  nervous  disease*  that  has  yet  appeared, 
and  were  international  jealousy  in  scientific  affairs 
at  all  pojsible,  we  might  be  excused  for  a  feeling  of 
chagrin  that  it  should  be  of  American  parentage. 
This  work,  however,  has  been  performed  in  New 
York,  and  has  been  so  well  performed  that  no  room 
i-<  left  for  anything  but  commendation.  With  great 
skill,  Dr.  Hamilton  has  presented  to  his  readers  a  suc- 


cinct and  lucid  survey  of  all  that  is  known  of  the 
pathology  of  the  nervous  system,  viewed  in  the  light 
of  the  most  recent  researches.  From  the  preliminary 
description  ofthe  methods  of  examination  and  study, 
and  of  the  instruments  of  precision  employed  in  the 
investigation  of  nervous  diseases,  up  till  the  final 
collection  of  formula,  the  book  is  eminently  prac- 
tical.—Brain,  London,  Oct.  1878. 


HENRY  C.  LEA— Philadelphia. 


C.    H,EA.'S 

(LATE  LEA  &  BLANCHAR&'s) 


OF 

MEDICAL  AND  SUEGICAL  PUBLICATIONS, 

In  asking  the  attention  of  the  profession  to  the  works  advertised  in  the  following 
pages,  the  publisher  would  state  that  no  pains  are  spared  to  secure  a  continuance  of 
the  confidence  earned  for  the  publications  of  the  house  by  their  careful  selection  and 
accuracy  and  finish  of  execution. 

The  printed  prices  are  those  at  which  books  can  generally  be  supplied  by  booksellers 
throughout  the  United  States,  who  can  readily  procure  for  their  customers  any  works 
not  kept  in  stock.  AVhere  access  to  bookstores  is  not  convenient,  books  will  be  sent 
by  mail  post-paid  on  receipt  of  the  price,  providing  their  weight  does  not  exceed  the 
postal  limit  of  four  pounds  (nee  page  32);  but  no  risks  are  assumed  either  on  the 
money  or  the  books,  and  no  publications  but  my  own  are  supplied.  Gentlemen  will 
therefore  in  most  cases  find  it  more  convenient  to  deal  with  the  nearest  bookseller. 

An  ILLUSTRATED  CATALOGUE,  of  64  octavo  pages,  handsomely  printed,  will  be  for- 
warded by  mail,  post-paid,  on  receipt  of  ten  cents. 

HENRY  C.  LEA. 

Nos.  706  and  708  SANSOM  ST.,  PHILADELPHIA,  April,  1879. 

ADDITIONAL  INDUCEMENT  FOR  SUBSCRIBERS  TO 

THE  AMERICAN  JOURNAL_OT  THE  MEDICAL  SCIENCES. 

THEEE  MEDICAL  JOUEtf  ALS,  containing  over  2000  LARGE  PAGES, 
Tree  of  Postage,  for  SIX  DOLLAKS  Per  Annum, 

TEEMS  FOB,  1879. 

The  AMERICAN  JOURNAL  OF  THK  MKDICAL  SCIENCES  and  1  Five  Dollars  per  annum, 
The  MEDICAL  NEWS  AND  LIBRARY,  both  free  of  postage,  )  in  advance. 

OR 
THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES,  published  quar-  1  q.    ,,  ,, 

terly  (1150  pages  per  annum),  with 

The  MEDICAL  NEWS  AND  LIBRARY,  monthly  (384  pp.  perannum),  and  [-  per  annum, 
THE   MONTHLY   ABSTRACT   OF   MEDICAL   SCIENCE  (592    pages    per  j  JQ  advance 
annum). 

SEPARATE  SUBSCRIPTIONS  TO 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES,  when  not  paid  for  in  advance. 

Five  Dollars. 

THE  MEDICAL  NEWS  AND  LIBRARY,  free  of  postage,  in  advance,  One  Dollar. 
THE  MONTHLY  ABSTRACT  OF  MKDICAL  SCIENCE,  tree  of  postage,  in  advance,  Two 

Dollars  and  a  Half. 

*#*  Advance-paying  subscribers  can  obtain  at  the  close  of  the  year  cloth  covers, 
gilt-lettered,  for  each  volume  of  the  Journal  (two  annually),  and  of  the  Abstract 
(one  annually),  free  by  mail,  by  remitting  ten  cents  for  each  cover. 

In  commencing  the  second  year  of  the  second  half  century  in  the  career  of  the 
"AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES,"  the  publisher  has  much  pleasure  in 
assuring  its  wide  circle  of  readers,  that  at  no  former  period  has  it  had  the  prospect  of 
a  more  extended  sphere  of  usefulness.  Sustained  as  it  is  by  the  profession  of  the  whole 
United  States,  and  with  a  circulation  extending  to  every  country  in  which  the  English 
language  is  read,  the  efforts  of  the  editors  will  be  directed,  as  heretofore,  to  render  it  in 
every  way  worthy  of  its  reputation,  and  of  the  universal  favor  with  which  it  is  received. 
With  its  attendant  periodicals,  the  "  M  KDICAL  NEWS  AND  LIBRARY"  and  the  "  MONTHLY 
A  BSTRACT  OF  M  EDiCALSciENCE,"  it  combines  the  advantages  of  the  elaborate  preparation 
which  can  be  given  to  a  quarterly,  and  the  prompt  conveyance  of  intelligence  by  the 
monthly,  while,  the  whole  being  under  a  single  editorial  supervision,  the  subscriber  is 
secured  against  the  duplication  of  matter  inevitable  under  other  circumstances.  These 
efforts  the  publisher  seeks  to  second  by  offering  these  periodicals  at  a  price  unprece- 
dentedly  low—  a  price  which  places  them  within  the  reach  of  every  practitioner,  and  gives 
the  equivalent  of  three  or  four  large  octavo  volumes  for  the  comparatively  trifling 

(For  THE  "OBSTETRICAL  JOUUNAL,"  see  p.  23.) 


2          HENRY  C.  LEA'S  PUBLICATIONS — (Am.  Journ.  Med.  Sciences'). 

cost  of  Six  DOLLARS  per  annum. 

The  three  periodicals  thus  offered  are  universally  known  for  their  high  professional 
standing  in  their  several  spheres. 

THE  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES, 

EDITED  BY  ISAAC  HAYS,  M.D.,  AND  I.  MINIS  HAYS,  M.D., 
is  published  Quarterly,  on  the  first  of  January,  April,  July,  and  October.  Each  num- 
ber contains  nearly  three  hundred  large  octavo  pages,  appropriately  illustrated  wher- 
ever necessary.  It  has  now  been  issued  regularly  for  over  FIFTY  years,  during  the 
whole  of  which  time  it  has  been  under  the  control  of  the  present  senior  editor.  Through- 
out this  long  period,  it  has  maintained  its  position  in  the  highest  rank  of  medical  peri- 
odicals both  at  home  and  abroad,  and  has  received  the  cordial  support  of  the  entire 
profession  in  this  country.  Among  its  Collaborators  will  be  found  a  large  number  of 
the  most  distinguished  names  of4he  profession  in  every  section  of  the  United  States, 
rendering  its  original  department  a  truly  national  exponent  of  American  medicine.* 

Following  this  is  the  -'REVIEW  DEPARTMENT,"  containing  extended  and  impartial 
reviews  of  important  new  works,  together  with  numerous  elaborate  "ANALYTICAL  AND 
BIBLIOGRAPHICAL  NOTICES"  giving  a  complete  survey  of  medical  literature. 

This  is  followed  by  the  "QUARTERLY  SUMMARY  OF  IMPROVEMENTS  AND  DISCOVERIES 
ix  THE  MEDICAL  SCIENCES,"  classified  and  arranged  under  different  heads,  presenting 
a  very  complete  digest  of  medical  progress  abroad  as  well  as  at  home. 

Thus,  during  the  year  1878,  the  "JOURNAL"  furnished  to  its  subscribers  77  Original 
Communications,  133  Reviews  and  Bibliographical  Notices,  and  255  articles  in  the 
Quarterly  Summaries,  making  a  total  of  FOUR  HUNDRED  AND  SIXTY-FIVE  articles 
illustrated  with  48  maps  and  wood  engravings,  emanating  from  the  best  professional 
minds  in  America  and  Europe. 

That  the  efforts  thus  made  to  maintain  the  high  reputation  of  the  "JOURNAL"  are 
successful,  is  shown  by  the  position  accorded  to  it  in  both  America  and  Europe  as  a 
leading  organ  of  medical  progress: — 

This  la  universally  acknowledged  as  the  leading 
American  Journal,  and  has  been  conducted  by  Dr. 
ll« ys  alone  until  1869,  when  his  son  was  associated 
with  him.  We  quite  agree  with  the  critic,  that  thi« 
journal  is  second  to  none  in  the  language,  and  cheer- 
fully accord  to  it  the  first  place,  for  nowhere  shall 
we  nnd  more  able  and  more  impartial  criticism,  and 
nowhere  such  a  repertory  of  able  original  articles. 
Indeed,  now  that  the  ''BrilUh  and  Foreign  Medico- 
Chirurgical  Review"  has  terminated  its  career,  the 
American  Journal  stands  without  a  rival. — London 
Med.  Times  and  Gazette,  Nov.  '24,  1877. 

The  present  number  of  the  American  Journal  is  an 
exceedingly  good  one,  and  gives  every  promise  of 
maintaining  the  well-earned  reputation  »f  the  review 
Our  venerable  contemporary  has  our  best  wishes, 
and  we  can  only  express  the  hope  that  it  may  con- 
tinue Us  work  with  as  much  vigor  and  excellence  for 
the  next  fifty  years  as  it  has  exhibited  in  the  past. 
—London  Lancet,  Nov.  24,  1877. 


The  Philadelphia  Medical  and  Physical  Journal 
issued  its  first  number  in  1820,  and  after  a  brilliant 
career,  was  succeeded  in  1827  by  the  American 
Journal  of  the  Medical  Sciences,  a  periodical  of 
world-wide  reputation  ;  the  ablest  and  one  of  the 
oldest  periodicals  in  the  world — a  journal  which  has 
an  unsullied  record. — Gross's  History  of  American 
Med.  Literature,  1S76. 

It  is  universally  acknowledged  to  be  the  leading 
American  medical  journal,  and,  in  our  opinion,  is 
second  to  none  in  the  language. —  Boston  Med.  and 
Surg.  Journal,  Oct.  1S77. 

This  is  the  medical  journal  of  our  country  to  which 
the  American  physician  abroad  will  point  with  the 
greatest  satisfaction,  as  reflecting  the  state  of  medical 
culture  in  his  country.  For  a  great  many  years  it 
has  been  the  medium  through  which  our  ablest  writ- 
ers have  made  known  their  discoveries  and  observa- 
tions — Address  of  L.  P.  Ynndell,  M.D.,  before  Inter- 
national Med.  Congress,  Sept.  1876. 


And  that  it  was  specifically  included  in  the  award  of  a  medal  of  merit  to  the  Publisher 
in  the  Vienna  Exhibition  in  1873. 

The  subscription  price  of  the  "AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES"  has 
never  been  raised  during  its  long  career.  It  is  still  FIVE  DOLLARS  per  annum  ;  and 
when  paid  for  in  advance,  the  subscriber  receives  in  addition  the  "MEDICAL  NEWS  AND 
LIBRARY,"  making  in  all  about  1500  large  octavo  pages  per  annum,  free  of  postage. 

II. 

THE  MEDICAL  NEWS  AND  LIBRARY    ' 

is  a  monthly  periodical  of  Thirty-two  large  octavo  pages,  making  384  pages  per 
annum.  Its  "LIBRARY  DEPARTMENT"  is  devoted  to  publishing  standard  works  on  the 
various  branches  of  medical  science,  paged  separately,  so  that  they  can  be  detached 
for  binding,  when  complete.  In  this  manner  subscribers  have  received,  without  ex- 
pense, such  works  as  '-WATSON'S  PRACTICE,"  "WEST  ON  CHILDREN,"  "MALGAIGNE'S 
SURGERY,"  "STOKES  ON  FEVER,"  GOSSELIN'S  "CLINICAL  LECTURES  ON  SURGERY,"  and 
many  other  volumes  of  the  highest  reputation  and  usefulness.  With  July,  1878,  was 
commenced  the  publication  of  "LECTURES  ON  DISEASES  OF  THE  NERVOUS  SYSTEM,"  by 
J.  M.  CHARCOT,  Professor  in  the  Faculty  of  Medicine  of  Paris,  translated  from  the 
French  by  GEORGE  SIGERSON,  M.D.,  Lecturer  on  Biology,  etc.,  Catholic  Univ.  of 

*  Communications  are  invited  from  gentlemen  in  all  parts  of  the  country.  Elaborate  articles  inserted 
by  the  Editor  are  paid  for  by  the  Publisher. 


HENRY  C.  LEA'S  PUBLICATIONS — (Am.  Journ.  Med.  Sciences).         3 

Ireland  (see  p.  17),  which  will  be  continued  to  completion  during  1879.  New  sub- 
scribers, commencing  with  January,  1879,  can  procure  the  previous  portion  by  a 
remittance  of  50  cents,  if  promptly  made. 

The  "NEWS  DEPARTMENT"  of  the  "MEDICAL  NEWS  AND  LIBRARY"  presents  the 
current  information  of  the  month,  with  Clinical  Lectures  and  Hospital  Gleanings. 
A  new  and  attractive  feature  of  this  will  be  found  in  an  elaborate  series  of  ORIGINAL 
AMERICAN  CLINICAL  LECTURES,  specially  contributed  to  the  News  by  gentlemen  of 
the  highest  reputation  in  the  profession  throughout  the  United  States.  During  1878 
there  have  appeared  Lectures  by 

S.  D.  GROSS,  M.D.,  Prof,  of  Surgery,  Jefferson  Med.  Coll.,  Philada. 

T.  GAILLARD  THOMAS,  M.D.,  Prof.  Obstetrics.  &c.,  Coll.  Phys.  and  Surg.,  N.  Y. 

WILLIAM  PEPPER,  M.D.,  Prof.  Clin.  Medicine,  Univ.  of  Penna. 

LEWIS  A.  SAYRE,  M.D.,Prof.  Orthopaedic  Surg..Bellevue  Hosp.Med  Coll.,  NY. 

ROBERTS  BARTHOLOW,  M.D.,  Prof.  Theory  and  Practice  of  Med.,  Med.  Coll.  of  Ohio. 

T.  G.  RICHARDSON,  M.D.,  Prof.  Genl.  and  Clin.  Surg.,  Univ.  of  La.,  New  Orleans. 

S.  W.  GROSS,  M.D.,  Surg.  to  Philada.  Hospital. 

P.  PEYRE  PORCHER,  M.D.,  Prof,  of  Mat.  Med.  and  Clin.  Medicine,  Med.  Coll.  of  S.  C. 

WILLIAM  GOODELL,  M.D.,  Prof.  Clin.  Gynaecology,  Univ.  of  Penna. 

N.  S.  DAVIS,  M.D..  Prof!  Prin  and  Pra'c.  of  Med.,  Chicago  Med.  Coll. 

W.  H.  VAN  BUREN,  M.D.,  Prof.  Surgery,  Bellevue  Hosp.  Med.  Coll.,  N.  Y. 
To  be  followed  by  others  of  similar  value  from 

AUSTIN  FLINT,  M.D..  Prof.  Prin.  and  Prac.  of  Med. .Bellevue  Hosp.  Med.  Coll.,  N.Y. 

FORDYCE  BARKER. M.I).,  Prof.  Clin.  Midwifery, &c.,  Bellevue  Hosp.Med.  Coll., N.Y. 

L.  A.  DUHRING.  M.D.,  Clin.  Prof,  of  Diseases  of  the  Skin,  Univ.  of  Penna. 

THKOPHiLUsPARViN,M.D.,Prof.  Obstetrics,  <fcc..  Coll.  Phys.  and  Surg., Indianapolis. 

J.  P.  WHITE,  M.D.,  Prof,  of  Obstetrics,  &c.,  Univ.  of  Buffalo. 

JOHN  ASHHCRST,  Jr.,  M.D.,  Prof,  of  Clin.  Surg.,  Univ.  of  Penna. 

D.  WARREN  BRICKELL,  M.D.,  Prof.  Obstetrics.  &c..  Charity  Hosp.  Med  Coll.,  N.  O. 

J.  LEWIS  SMITH,  M.D.,  Clin.  Lee.  on  Dis.  of  Chil.,  Bellevue  Hosp.  Med.  Coll.,  N.  Y. 

WILLIAM  F.  NORRIS,  M.D.,  Clin.  Prof,  of  Diseases  of  the  Eye,  Univ.  of  Penna. 

P.  S.  CONNER,  M.D.,  Prof,  of  Anat.  and  Clin.  Surgery,  Med.  Coll.  of  Ohio,  Cin. 

S.  WEIR  MITCHELL,  M.D.,  Phys.  to  the  Infirmary  for  Nervous  Diseases.  Philada. 

J.  M.  DACOSTA,  M.D.,  Prof.  Prin.  and  Prac.  of  Med.,  Jeff.  Med.  Coll.,  Philada. 

THOMAS  G.  MORTON,  M.D.,  Surgeon  to  Penna.  Hospital,  Philada. 

F.  J.  BUMSTEAD,  M.D.,  late  Prof,  of  Venereal  Dis.,  Coll.  Phys.  and  Surg.,  N.  Y. 

J.  H.  HUTCHINSON,  M.D.,  Physician  to  Penna.  Hospital. 

CHRISTOPHER  JOHNSON,  M.D.,  Prof,  of  Surgery,  Univ.  of  Md.,  Baltimore. 

WILLIAM  THOMSON,  M.D.,  Lecturer  on  Ophthalmology,  Jeff.  Med.  Coll.,  Philada. 

With  contributors  such  as  these,  representing  every  portion  of  the  United  States, 
the  publisher  feels  safe  in  promising  to  the  subscriber  a  series  of  practical  lectures 
unsurpassed  in  variety,  interest,  and  value. 

As  stated  above,  the  subscription  price  of  the  "  MEDICAL  NEWS  AND  LIBRARY"  is 
ONE  DOLLAR  per  annum  in  advance ;  and  it  is  furnished  without  charge  to  all  advance- 
paying  subscribers  to  the  "AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES." 

III. 

THE  MONTHLY  ABSTRACT  OF  MEDICAL  SCIENCE 

is  issued  on  the  first  of  every  month,  each  number  containing  forty-eight  large  octavo 
pages,  thus  furnishing  in  the  course  of  the  year  about  six  hundred  pages.  The  aim 
of  the  "  ABSTRACT"  is  to  present — without  duplicating  the  mutter  in  the  "JOURNAL" 
and  "NEWS" — a  careful  condensation  of  all  that  is  new  and  important  in  the  medical 
journalism  of  the  world,  and  all  the  prominent  professional  periodicals  of  both  hemi- 
spheres are  at  the  disposal  of  the  Editors.  To  show  the  manner  in  which  this  plan 
has  been  carried  out  it  is  sufficient  to  slate  that  during  the  year  1878  it  contained — 

3O  Articles  on  Anntotny  and  J'lii/.\iol»f/i/. 

56          "  "     Mfiti-ria  Medica  and  '1'lierapeutica. 

23O          "  "     JU<-(liciiie. 

lot  "  "     Siirfferj/. 

79         '•  "    Midurifpry  and  fiifmecolofji/. 

iy          "          "    Mrdical  Jurisprudence  and  Toxicology — 

making  in  all  558  articles  in  a  single  year. 

The  subscription  to  the  "MONTHLY  ABSTRACT,"  free  of  postage,  is  Two  DOLLARS 
AND  A  HALF  a  year,  in  advance. 

As  stated  above,  however,  it  will  be  supplied  in  conjunction  with  the  "AMERICAN 
JOURNAL  OF  THE  MEDICAL  SCIENCES"  and  the  "MEDICAL  NEWS  AND  LIBRARY,"  making 
in  all  about  TWENTY-ONE  HUNDRED  pages  per  annum,  the  whole  free  of  postage,  for 
Six  DOLLARS  a  year,  in  advance. 

In  this  effort  to  bring  so  large  an  amount  of  practical  information  within  the  reach 
of  every  member  of  the  profession,  the  publisher  confi  iently  anticipates  the  friendly 


HENIIY  C.  LEA'S  PUBLICATIONS — (Dictionaries). 


aid  of  all  who  are  interested  in  the  dissemination  of  sound  medical  literature.  He 
trusts,  especially,  that  the  subscribers  to  the  ''AMERICAN  MEDICAL  JOURNAL"  will  call 
the  attention  of  their  acquaintances  to  the  advantages  thus  offered,  and  that  he  will 
be  sustained  in  the  endeavor  to  permanently  establish  medical  periodical  literature 
on  a  footing:  of  cheapness  never  heretofore  attempted. 

PREMIUM  FOR  OBTAINING  NEW  SUBSCRIBERS  TO  THE  "JOURNAL," 

Any  gentleman  who  will  remit  the  amount  for  two  subscriptions  for  1879,  one  of 
which  must  be  for  a  new  ntbscriber,  will  receive  as  a  PREMIUM,  free  by  mail,  a  copy  of 
"  HOLOEN'S  LANDMARKS.  MKIHOAL  AND  SURGICAL"  (for  advertisement  of  which  see  p. 
6),  or  of  FOTHEKGILL'S  "  ANTAGONISM  OF  MEDICINES"  (see  p.  lf>),  or  of  "BROWNE  ON 
THE  USE  OF  THE  OPHTHALMOSCOPE"  (see  p.  29),  or  of  "  FLINT'S  ESSAYS  ON  CONSERVATIVE 
MEDICINE"  (see  p.  15),  or  of  "STURGKS'S  CLINICAL  MKDICINE"  (see  p.  14),  or  of  the 
new  edition  of  "SWAYNE'S  OBSTETRIC  APHORISMS"  (see  p.  21),  or  of  "TANNER'S 
CLINICAL  MANUAL"  (see  p.  5),  or  of  "CHAMBERS'S  RESTORATIVE  MEDICINE"  (see  p. 
18),  or  of  "  WEST  ON  NERVOUS  DISORDERS  OF  CHILDREN"  (see  p.  20). 

*V*  Gentlemen  desiring  to  avail  themselves  of  the  advantages  thus  offered  will  do 
well  to  forward  their  subscriptions  at  an  early  day,  in  order  to  insure  the  receipt  of 
complete  sets  for  the  year  1879. 

Ig^  The  safest  mode  of  remittance  is  by  bank  check  or  postal  money  order,  drawn 
to  the  order  of  the  undersigned.  Where  these  are  not  accessible,  remittances  for  the 
"JOURNAL"  may  be  made  at  the  risk  of  the  publisher,  by  forwarding  in  REGISTERKD 
letters.  Address, 

HENRY  C.  LEA,  Nos.  706  and  708  SANSOM  ST.,  PHILADELPHIA,  PA. 

T\UNOLISON  (ROBLEY),  M.D., 

Late  Professor  of  Institutes  of  Medieinein  Jefferson  Medical  College,  Philadelphia. 

MEDICAL  LEXICON;  A  DICTIONARY  OP  MEDICAL  SCIENCE:  Con- 
taining a  concise  explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Pathology,  Hygiene,  Therapeutics.  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical 
Jurisprudence,  and  Dentistry.  Notices  of  Climate  and  of  Mineral  Waters ;  Formulae  for 
Officinal,  Empirical,  and  Dietetic  Preparations;  with  the  Accentuation  and  Etymology  of 
the  Terms,  and  the  French  and  other  Synonymes ;  so  as  to  constitute  a  French  as  well  a? 
English  Medical  Lexicon.  A  Ne,w  Edition.  Thoroughly  Revised,  and  very  greatly  Mod- 
ified and  Augmented.  By  RICHARD  J.  DUNGLISON,  M.D.  In  one  very  large  and  hand- 
some  royaloctavo  volume  of  over  1100  pages.  Cloth,  $6  50;  leather,  raised  bands,  $7  50. 
(Just  Issued.) 

The  object  of  the  author  from  the  outset  has  not  been  to  make  the  work  a  mere  lexicon  or 
dictionary  of  terms,  but  to  afford,  undereach,  a  condensed  view  of  its  various  medical  relations, 
and  thus  to  render  the  work  an  epitome  of  the  existing  condition  of  medical  science.  Starting 
with  this  view,  the  immense  demand  which  has  existed  for  the  work  has  enabled  him,  in  repeated 
revisions,  to  augment  its  completeness  and  usefulness ,  until  at  length  it  has  attained  the  position 
of  a  recognized  and  standard  authority  wherever  the  language  is  spoken. 

Special  pains  have  been  taken  in  the  preparation  of  the  present  edition  to  maintain  this  en  • 
viable  reputation.  Duringthe  ten  years  which  have  elapsed  since  the  last  revision,  the  additions 
to  the  nomenslature  of  the  medical  sciences  have  been  greater  than  perhaps  in  any  similar  period 
of  the  past,  and  up  to  the  time  of  his  death  the  author  la  bored  assiduously  to  incorporate  every- 
thing requiring  the  attention  of  the  student  or  practitioner.  Since  then,  the  editor  hns  been 
equally  industrious,  so  that  the  additions  to  the  vocabulary  are  more  numerous  than  in  any  pre- 
vious revision.  Especial  attention  has  been  bestowed  on  the  accentuation,  which  will  be  found 
marked  on  every  word.  The  typographical  arrangement  has  been  much  improved,  rendering 
reference  much  more  easy,  and  every  care  has  been  taken  with  the  mechanical  execution.  The 
work  has  been  printed  on  new  type,  small  but  exceedingly  clear,  with  an  enlarged  page,  so  that 
the  additions  have  been  incorporated  with  an  increase  of  but  little  over  a  hundred  pages,  and 
the  volume  now  contains  the  matter  of  at  least  four  ordinary  octavos. 


A  book  well  known  to  our  readers,  and  of  which 
every  American  ought  to  be  proud.  When  the  learned 
author  of  the  work  passed  away,  probably  all  of  us 
feared  lest  the  book  should  not  maintain  its  place 
in  the  advancing  science  whose  terms  it  defines.  For- 
tunately, Dr.  Kichard  J.  Dunglison,  having  assisted  his 
father  in  the  revision  of  several  editions  of  the  work, 
and  having  been,  therefore,  trained  in  the  methods  and 
imbued  with  the  spirit  of  the  book,  has  been  able  to 
edit  it.  not  in  the  patchwork  manner  so  dear  to  the 
heart  of  book  editors,  so  repulsive  to  the  taste  of  intel- 
ligent book  readers,  but  to  flit  it  as  a  work  of  the  kind 
should  be  edited — to  carry  it  on  steadily,  without  jar 
or  interruption,  along  the  grooves  of  thought  it  has 
travelled  during  its  lifetime.  To  show  the  magnitude 
of  the  task  which  Dr  Dunglison  has  assumed  and  car- 
ried through,  it  is  only  necessary  to  stale  that  more 
than  six  thousand  new  subjects  have  been  added  in  the 
presentedition. — I'htla.Med.  Times,  Jan.  3,  1874. 

About  the  first  book  purchased  by  the  medical  stu- 
dent i*  the  Medical  Dictionary.  The  lexicon  explana- 
tory of  technical  terms  is  simply  a  sine  qua  ncn.  In  a 


science  so  extensive,  and  with  such  collaterals  as  medi- 
cine, it  is  as  much  a  necessity  also  to  the  practising 
.ihysii-ian.  To  meet  the  wants  of  students  and  most 
;ihysii  i:-.ns,  the  dictionary  must  be  condensed  while 
jomprehensive,  and  practical  while  perspicacious.  It 
was  because  Dunglison's  met  these  indication?  that  it 
became  at  once  the  dictionary  of  general  use  wherever 
medicine  was  studied  in  the  English  language.  In  no 
former  revision  have  the  alterations  and  additions  been 
•>o  great.  More  than  six  thousand  new  subjects  and  terms 
have  been  added.  The  chief  terms  have  been  set  in  black 
letter,  while  the  derivatives  follow  in  small  caps;  an 
arrangement  which  greatly  facilitates  reference.  We 
may  safely  confirm  the  hope  ventured  by  the  editor 
"  that  the  work,  which  possesses  forhim  a  filial  as  well 
*s  an  individual  interest,  will  be  found  worthy  a  con- 
tinuance of  the  position  so  long  accorded  to  it  as  a 
ftandard  authority."  —  Cincinnati  Clinic.  Jan.  10,  1874. 
It  has  the  rare  merit  that  it  certainly  has  no  rival 


references.  —  London  Medical  Gazette. 


HENRY  C.  LEA'S  PUBLICATIONS — (Manuals^. 


A    CENTURY  OF  AMERICAN  MEDICINE,  1776-1876.     By  Doctors  K.  II. 
•"•      Clarke,  H.  J.  Bigelow,  S.  D.  Gross,  T.  G.  Thom.-is,  and  J.  S.  Billings,  "in  one  very  hand- 
some  12mo.  volume  of  about  350  pages  :  cloth.  $2  25.      (Just  Ready.) 

This  work  appeared  in  the  pages  of  the  American  Journal  of  the  Medical  Science? during  the 
year  1876.   As  a  detailed  account  of  the  development  of  medical  science  in  America,  by  gentle 
men  of  the  highest  authority  in  their  respective  departments,  the  profession  will  no  doubt  wel- 
come  it  in  a  form  adapted  for  preservation  and  reference. 


'OBLYN  (RICHARD  D.),  M.D. 

A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AKD 

THE  COLLATERAL  SCIENCES.     Revised,  with  numerous  additions,  by  ISAAC  HAYS, 
M.  D.,  Editor  of  the  "American  Journal  of  the  Medical  Sciences."     In  one  large  royal 
12mo.  volume  of  over  500  double-columned  pages  ;  .cloth,  $1  50  ;  leather,  $2  00 
It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  table. — Southern 
Xed.  and  Surg  Journal. 

T>OD  WELL  (G.  F).  F.R.A.S.,  £c. 

A  DICTIONARY  OF  SCIENCE:  Comprising  Astronomy,  Chem- 

istry,  Dynamics,  Electricity.  Heat,  Hydrodynamics,  Hydrostatics,  Light,  Magnetism, 
Mechanics,  Meteorology,  Pneumatics,  Sound,  and  Statics.  Preceded  by  an  Essay  on  the 
History  of  the  Physical  Sciences.  In  one  handsome  octavo  volume  of  694  pages,  and 
many  illustrations  :  cloth,  $5. 

ffEILL  (JOHN),  M.D.,  and     &MITH  (FRANCIS  G.),  M.D., 

Prof  .of  the  Institutes  of  Medicine  inthe  Univ.of  Pennc . 

AN    ANALYTICAL    COMPENDIUM   OF   THE    VARIOUS 

BRANCHES  OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.  A 
new  edition,  revised  and  improved.  In  one  very  large  and  handsomely  printed  royal  12mi. 
volume,  of  about  one  thousand  pages,  with  374  wood-cuts,  cloth,  $4  ;  strongly  bound  in 
leather,  with  raised  bands,  $4  75. 

HARTSHORN E  (HENRY),  M.D., 

Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A    CONSPECTUS    OF    THE   MEDICAL   SCIENCES;    containing 

Handbooks  on  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Practical  Medicine, 
Surgery,  and  Obstetrics.  Second  Edition,  thoroughly  revised  and  improved.  In  one  large 
royal  12mo.  volume  of  more  than  1000  closely  printed  pages,  with  477  illustrations  en 
wood.  Cloth,  $4  25  ;  leather,  $5  00.  (Lately  Issued.) 

We  can  say  with  the  strictest  truth  that  it  is  the  j  dents,  but  to  many  others  whomay  desire  torefrefh 
best  work  ofthekind  with  which  we  are  acquainted  j  their  memories  with  the  smallest  possible  expends  - 
It  embodies  ina  condensed  form  all  recent  contribn-  ture  of  time. — N.  T.  Med.  Journal,  Sept.  1874. 


tions  to  practical  medicine,  and  is  therefore  useful 
to  every  busy  practitioner  throughout  our  country, 
besides  being  admirably  adapted  to  the  use  of  stu- 
dents of  medicine.  The  book  is  faithfully  and  ably 
executed.— Charleston  Med.  Journ.,  April,  1875 

The  work  is  intended  as  an  aid  to  the  medical 
stu  lent,  and  as  such  appears  to  admirably  fulfil  its 
object  by  itsexcellent  arrangement,  the  full  compi- 


The  student  will  find  this  the  most  convenient  and 
useful  book  of  the  kind  on  which  he  can  lay  his 
hand. — Pacific  Med.  and  Surg.  Journ.,  Aug.  1874. 

This  is  the  best  book  of  its  kind  that  we  have  ever 
examined.  It  is  an  honest,  accurate,  and  concue 
compend  of  medical  sciences,  as  fairly  as  possible 
representing  their  present  condition.  The  changes 
and  the  additions  have  been  so  judicious  and  tho- 


lation  jf  facts,  the  perspicuity  aud  terseness  of  Ian-  j  Toug^  ag  to  render  it.  so  far  as>  it  goes,  entirely  trnst- 
guage,  and  the  clear  and  instructive  illustrations     worthy.     If  students  must  have  a  conspectus,  they 


will  be  wise  to  procure  that  of  Dr.  Hartshorne. — 
Detroit  Rev.  of  Med  and  P/iarm.,  Aug.  1874. 


in  some  parts  of  the  work  — American  Journ.  of 
Pharmacy,  Philadelphia,  July,  1874. 
The  volume  will  be  found  useful,  not  only  to  stn- 

fUDLOW  (J.L.),  M.D. 

A   MANUAL   OF  EXAMINATIONS  upon  Anatomy,  Physiology, 

Surgery,  Practice  of  Medicine,  Obstetrics,  Materia  MeJica,  Chemistry,  Pharmacy,  and 
Therapeutics.  To  which  is  added  a  Medical  Formulary.  Third  edition,  thoroughly  revised 
and  greatly  extended  and  enlarged.  With  370  illustrations.  In  one  handsome  royal 
12mo.  volume  of  816  large  pages,  cloth,  $3  25  ;  leather,  $3  75. 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  especially  suit- 
able for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 

/TANNER  (THOMAS  HA  WKES),  M.D.,  frc. 

A  MANUAL  OF  CLINICAL  MEDICINE  AND  PHYSICAL  DIAO- 

NOSIS.  Third  American  from  the  Second  London  Edition.  Revised  and  Enlarged  by 
TILBURY  Fox,  M.  D.,  Physician  to  the  Skin  Department  in  University  College  Hospits  , 
Ac.  In  one  neat  volume  small  12mo.,  of  about  375  pages,  cloth.  $150. 

***  On  page  4,  it  will  be  seen  tha1;  this  work  is  offered  as  a  premium  for  procuring  new 
subscribers  to  the  "AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES/' 


HENRY  C.  LEA'S  PUBLICATIONS  -(Anatomy^. 


(HENRY),  F.R.S., 

Ltcturer  on  Anatomy  at  St.  George's  Hospital,  London. 

ANATOMY,  DESCRIPTIVE    AND  SURGICAL.     The  Drawings  by 

H.  V.  CARTER,  M.D.,  and  Dr.  WESTMACOTT.  The  Dissectionsjointly  by  the  AUTHOR  and 
Dr.  CARTER.  With  an  Introduction  on  General  Anatomy  and  Development  by  T. 
HOLMES,  M.A.,  Surgeon  to  St.  George's  Hospital.  A  new  American,  from  the  eighth 
enlargec  and  improved  London  edition.  To  whicn  is  added  "  LANDMARKS,  MEDICAL  AND 
SURGICAL,"  by  LUTHER  HOLDEN,  F.R  C.S.,  author  of  "  Human  Osteology,"  "  A  Manual 
of  Dissections,"  etc.  In  one  magnificent  imperial  octavo  volume  of  983  pages,  with 
522  large  and  elaborate  engravings  on  wood.  Cloth,  $6  ;  leather,  raised  bands,  $7. 
(Just  Ready.) 

The  author  has  endeavored  in  this  work  to  cover  a  more  extended  range  of  subjects  than  is  cus- 
tomary in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  student,  br,t 
alaothe  application  of  those  details  in'the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  guide  for  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  en- 
gravings form  a  special  feature  in  the  work,  many  of  them  being  thesise  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  of 
figures  of  reference,  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  splendid  series, 
wuich  will  greatly  assist  the  student  in  obtaining  a  clear  idea  of  Anatomy,  and  will  also  serve  to 
refresh  the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recalling 
the  details  of  the  dissecting  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with 
a  thorough  treatise  on  systematic,  descriptive,  and  applied  Anatomy,  the  work  will  be  found  of 
essential  use  to  all  physicians  who  receive  students  in  their  offices,  relieving  both  preceptor  and 
pupil  of  much  labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

Since  the  appearance  of  the  last  American  Edition,  the  work  has  received  three  revisions  at  the 
hands  of  its  accomplished  editor,  Mr.  Holmes,  who  has  sedulously  introduced  whatever  ha?  seemed 
requisite  to  maintain  its  reputation  as  acomplete  and  authoritative  standard  text-book  and  work 
of  reference.  Still  further  to  increase  its  usefulness,  there  has  been  appended  to  it  the  recent 
work  by  the  distinguished  anatomist,  Mr.  Luther  Holden — "Landmarks,  Medical  and  Surgical" 
— which  gives  in  a  clear,  condensed,  and  systematic  way,  all  the  information  by  which  the  prac- 
titioner can  determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work,  it  is  believed,  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  study.  No  pains  have  been  spared  in  the  typographical  execution  of 
the  volume,  which  will  be  found  in  all  respects  superior  to  former  issues.  Notwithstanding  the 
increase  of  size,  amounting  to  over  100  pages  and  57  illustrations,  it  will  be  kept,  as  heretofore, 
at  a  price  rendering  it  one  of  the  cheapest  works  ever  offered  to  the  American  profession. 


The  recent  work  of  Mr  Holden,  which  was  no- 
ticed by  u»  on  p.  53  of  this  volume,  has  been  added 
a*  an  appendix,  so  that,  altogether,  this  is  the  moit 
practical  and  complete  anatomical  treatise  available 
to  American  students  and  physicians.  The  former 
finds  in  it  the  necessary  guide  in  makicg  dissec- 
tions; *  very  comprehensive  chapter  on  minute 
anatomy  ;  and  about  all  that  can  be  taught  him  on 
general  and  special  anatomy;  while  the  latter,  in 
it*  treatment  of  each  region  from  a  surgical  point  of 
view,  and  in  the  valuable  edition  of  Mr  Holden, 
will  find  all  that  will  be  essential  to  him  in  his 
practice  —New  Remtd'es,  Aug  1S78. 

This  work  is  as  near  perfection  as  one  could  pos- 
sibly or  reasonably  expect  any  book  intended  ax  a 
text-'book  or  a  general  reference  book  on  anatomy 
to  be.  The  American  publisher  deserves  the  thanks 
of  th«  profession  for  appending  the  recent  work  of 
Mr.  Holden,  "Landmarks,  Medical  and  Surpical," 
which  has  already  been  commended  as  a  separate 


to  consult  his  books  on  anatomy.  The  work  is 
simply  indispensable,  especially  this  present  Amer- 
ican edition.—  Va.  Med.  Monthly,  Sept.  187P. 

The  addition  of  the  recent  work  of  Mr.  Holden, 
as  an  appendix,  renders  this  the  most  practical  and 
complete  treatise  available  to  American  students, 
who  find  in  it  a  comprehen»ive  chapter  on  minute 
anatomy,  about  all  that  can  be  taught  on  general 
and  special  anatomy,  while  its  treatment  of  each 
region,  from  a  surgical  point  of  vie  T,  in  the  valu- 
able section  by  Mr  Hoi  den. is  all  that  will  be  essen- 
tial to  them  in  practice. — Ohio  Mtdical  Recorder, 
Aug  1S7S. 

It  is  difficult  to  speak  in  moderate  terms  of  this 
new  edition  of  "Gray."  It  seems  to  be  as  nearly 
perfect  as  it  is  possible  to  make  a  book  devoted  to 
any  branch  of  medical  science.  The  labors  of  the 
eminent  wen  who  have  successively  revised  the 
eight  editions  through  which  it  has  passed,  would 


book.    The  latter  work — treating  of  topographical  i  seem. to  leave  nothing  for  future  editor*  to  do.     The 


anatomy — has  become  an  essential  to  the  library  of 
every  intelligent  practitioner.  We  know  of  no 
book  that  can  take  its  place,  written  as  it  is  by  a 
most  distinguished  anatomist.  It  would  be  simply 
a  waste  of  words  to  say  anything  farther  in  praise 
of  Gray's  Anatomy,  the  text-book  in  almost  every 
medical  college  in  this  country,  and  the  daily  refer- 
ence book  of  every  practitioner  who  has  occasion 


addition  of  Holden's  "  Landmarks"  will  make  it  as 
indispensable  to  the  practitioner  of  medicine  and 
surgery  as  it  has  been  heretofjre  to  the  student.  As 
regards  completeness,  ease  of  reference,  utility, 
beauty,  and  cheapness,  it  has  no  rival.  No  stu- 
dent should  enter  a  medical  school  without  it  ;  no 
physician  can  afford  to  have  it  absent  from  his 
library  —St.  Louis  Clin.  Rtcord,  Sept.  1878. 


ALSO  FOR  SALE  SEPARATE  — 

TTOLDEN  (LUTHER),  F.R.C.S., 

Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals. 

LANDMARKS,  MEDICAL  AND  SURGICAL.    From  the  2d  London 

Ed.  In  one  handsome  volume,  royal  12mo.,  of  128  pages  :  cloth,  88  cents.  (Now  Ready.) 
The  title  of  this  book  is  very  suggestive  of  its  transparent  before  him,  is  incalculable.  The  map- 
practical  value,  while  the  perusal  of  the  work  itself  ping  out  of  the  human  body  is  one  which  is  most  in- 
Terifles  the  most  extravagant  expectations.  The  nructive  to  the  practical  man,  and  he  is  enabled, 
object  of  the  author  has  been  to  collect  iu  compact  after  considerable  experience,  to  have  landmark* 
form  thelandmarkn,ornnrface-markKoftbediflVrent  of  his  own;  but  in  the  little  work  before  ns  this 
partt  of  the  body,  aiid  indicate  tbeir  relation  to  the  knowledge  is  systematized  in  such  an  intelligible 
deeper-seated  parts.  The  valne  of  Ihissortof  know-  manner  as  to  place  it  within  ihe  roach  of  all  It  is 
I-dge  to  'he  pby-irian,  but  especially  to  the  surgeon  :  one  of  the  most  intf  restiEgliltle  works  we  have  neen 
who.  with  anaiomical  eye,  con  make  the  tissues  for  a  long  time. — A.  1".  Med.  Record,  May  11,  1878. 


HENRY  C.  LEA'S  PUBLICATIONS — (Anatomy'}. 


A  LLEN  (HARRISON],  M.D. 

-£*-  Prnffs*or  of  Physiology  in  the.  Univ.  of  Pa. 

A  SYSTEM  OP  HUMAN  ANATOMY:  INCLUDING  ITS  MEDICAL 

and  Surgical  Relations.  For  the  Use  of  Practitioners  and  Students  of  Medicine.   With  an 
Introductory  Chapter  on  Histology.  By  E.  0.  SHAKESPEARE,  M  D  ,  Ophthalmologist  to  the 
Phila.  Hosp.    In  one  large  and  handsome  quarto  volume,  with 'several  hundred  original 
illustrations  on  lithographic  plates,  and  numerous  wood-cuts  in  the  text.      (Preparing.) 
In  this  elaborate  work,  which  has  been  in  active  preparation  for  several  years,  the  author  has 
sought  to  give,  not  only  the  details  of  descriptive  anatomy  in  a  clear  and  condensed  form,  but  also 
the  practical  applications  of  the  science  to  medicine  and  surgery.  The  work  thus  has  claims  upon 
the  attention  of  the  general  practitioner,  as  well  as  of  the  student,  enabling  him  not  only  to  re- 
fresh his  recollections  of  the  dissecting  room,  but  also  to  recognize  thesignificance  of  all  varia- 
tions from  normal  conditions.     The  marked  utility  of  the  object  thus  sought  by  the  author  is 
self-evident,  and  his  long  experience  and  assiduous  devotion  to  its  thorough  development  are  a 
sufficient  guarantee  of  the  manner  in  which  his  aims  have  been  carried  out.  No  pains  have  been 
spared  with  the  illustrations.  Those  of  normal  anatomy  are  from  original  dissecti  ..ns,  drawn  on 
stone  by  Mr.  Hermann  Faber,  with  the  name  of  every  part  clearly  engraved  upon  the  figure, 
after  the  manner  of  "  Holden"  and  "  Gray,"  and  in  every  typographical  detail  it  will  be  the 
effort  of  the  publisher  to  render  the  volume  worthy  of  the  very  distinguished  position  which  is 
anticipated  for  it. 

J?LLIS  (GEORGE   V1\ER}~ 

J-J  Emeritus  Professor  rf  Anatomy  in  University  College.,  London. 

DEMONSTRATIONS  IN  ANATOMY;  Being  a  Guide  to  the  Know- 
ledge of  the  Human  Body  by  Dissection.  By  GEORGE  VIXER  ELLIS,  Emeritus  Professor 
of  Anatomy  in  University  College,  London.  From  the  Eighth  and  Revised  London 
Edition.  In  one  very  handsome  octavo  volume  of  over  700  pages,  with  256  illustrations. 
(Nearly  Ready.) 

This  work  has  long  been  known  in  England  as  the  leading  authority  on  practical  anatomy, 
aTid  the  favorite  guide  in  the  dissecting-room,  ns  is  attested  by  the  numerous  editions  through 
•which  it  has  passed.  In  the  last  revision,  which  has  just  appeared  in  London,  the  accomplished 
author  has  sought  to  bring  it  on  a  level  with  the  most  recent  advances  of  science  by  making  the 
necessary  changes  in  his  account  of  the  microscopic  structure  of  the  different  organ?,  as  devel- 
oped by  the  latest  researches  in  textural  anatomy. 

'ILSON  (ERASMUS),  F.R.S. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.  Edited 

by  W.  H.  GOBRECIIT,  M.D  ,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  Col- 
lege of  Ohio.  Illustrated  with  three  hundred  and  ninety-seven  engravings  on  wood.  In 
one  large  and  handsome  octavo  volume,  of  over  fiOO  large  pages  ;  cloth,  $4  ;  leather.  $6. 

fJEATH  (CHRISTOPHER),  F.R.C.S., 

fJ-  Teacher  of  Operative.  Surgery  in  University  College,  London. 

PRACTICAL  ANATOMY:    A  Manual  of  Dissection?.     From  the 

Second  revised  and  improved  London  edition.  Edited,  with  additions,  by  W.  W.  KEEN, 
M.  D.,  Lecturer  on  Pathological  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia. 
In  one  handsome  royal  12ino. volume  of  578  pages,  with  247  illustrations.  Cloth,  $350; 
leather,  $4  00. 

VMITH  (HENRY  H.),  M.D.,         and  CORNER  (  WILLIAM  E.),  M.D., 

Prof,  of  Surgery  in  the  Univ.  of  Penna. ,  Ac.  "     Late  Prof,  of  Anatomy  in  the  Univ.  of  Per.  na. 

AN    ANATOMICAL   ATLAS,  illustrative  of  the  Structure  of  the 

Human  Body.  In  one  volume,  large  imperial  octavo,  eloth,  with  about  six  hundred  and 
fifty  beautitul  figures.  $4  50. 


T>ELLAMY(E.),F.R.C.S. 
™  ' 


THE  STUDENT'S  GUIDE  TO  SURGICAL  ANATOMY:  A  Text- 

Book  for  Students  preparing  for  their  Pass  Examination.    With  engravings  on  wood.  In 
one  handsome  royal  12mo.  volume.     Cloth.  $2  25.     (Lately  Published.) 

riLELAND  (JOHX),N.D., 

L/  professor  of  Anatomy  and  Physiology  in  Queen's  College,  Galway. 

A    DIRECTORY  FOR  THE    DISSECTION  OF  THE  HUMAN  BODY. 

In  one  small  volume,  royal  12mo.  of  182  pages:  cloth,  $1  25.     (Just  Issued.) 

VCHAFER  (EDWARD  ALBERT),  M.D., 

O  A»sistan  t  Prof  et  tor  of  Physiology  in  University  College,  London. 

A  COURSE  OF  PRACTICAL  HISTOLOGY:  Being  an  Introduction  to 

the  Use  of  the  Microscope.     In  one  handsome  royal  12mo.  volume  of  304  pages,  with 
numerous  illustrations:  cloth,  $2  00.     (Jnst  Issued.) 

HORNER'S  SPECIAL   ANATOMY  AND   HISTOL-  1  SHARPEY    AND    CHAIN'S    HUMAN    ANATOMY. 
OQY      Eighth  edition,  extensively  rpviaed  aod         Revised,  by  JO«KPH  LRIDT,  MI).,  Prof  of  Anal. 
li'««d      Tn  S  vola     Svo     of  over  1000   pages          in  U.,iv.  of  Penn.     In  two  octavo  voli.  of  abont 
'1  1      lSOOpage.Iwi,h511illu.tr.tlon..    Cloth,$60<. 


8 


HENRY  C.  LEA'S  PUBLICATIONS — (Physiology}. 


CARPENTER  (  WILLIAM  B.),  M.  D.,  F.R.S.,  F.G.S.,  F.L.S., 

Registrar  to  University  of  London,  etc. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  Edited  by  HENRYPOWER, 

M.B.  Lond.,  F.R.C.S.,  Examiner  in  Natural  Sciences,  University  of  Oxford.     Anew 
American  from  the  Eighth  Revised  and  Enlarged  English  Edition,  with  Notes  and  Addi- 
tions, by  FRANCIS  G.  SMITH,  M.D.,  Professor  of  the  Institutes  cf  Medicine  in  the  Univer- 
sity of  Pennsylvania,  etc.  In  one  very  large  and  handsome  octavo  volume,  of  1083  pages, 
with  two  plates  and  373  engravings  on  wood;  cloth,  $5  50  ;  leather,  $6  50.    (Just  Issued.) 
The  great  work,  the  crown  ing  labor  of  the  distinguished  author,  and  through  which  so  many 
generations  of  students  have  acquired  their  knowledge  of  Physiology,  has  been  almost  meta- 
morphosed in  the  effort  to  aCapt  it  thoroughly  to  the  requirements  of  modern  science.    Since 
the  appearance  of  the  last  American  edition,  it  has  had  several  revisions  at  the  experienced 
hand  of  Mr.  Power,  who  has  modified  and  enlarged  it  so  as  to  introduce  all  that  is  important 
in  the  investigations  and  discoveries  of  England,  France,  and  Germany,  resulting  in  an  enlarge- 
ment of  about  one-fourth  in  the  text.   The  series  of  illustrations  has  undergone  a  like  revision  , 
a  large  proportion  of  the  former  ones  having  been  rejected,  and  the  total  number  increased 
to  nearly  four  hundred.     The  thorough  revision  which  the  work  has  so  recently  received  in 
England,  has  rendered  unnecessary  any  elaborate  additions  inthis  country,  but  the  American 
Editor,  Professor  Smith,  has  introduced  such  matters  as  his  long  experience  has  shown  him  to 
be  requisite  for  the  student.   Every  care  has  been  taken  with  the  typographical  execution  ,  and 
the  work  is  presented,  with  its  thousand  closely,  but  clearly  printed  pages,  as  emphatically  the 
text-book  for  the  student  and  practitioner  of  medicine — the  one  in  which,  as  heretofore,  especial 
care  is  directed  to  show  the  applications  of  physiology  in  the  various  practical  branches  of 
medical  science.     Notwithstanding  its  very  great  enlargement,  the  price  has  not  been  in- 
creased, rendering  this. one  of  the  cheapest  works  now  before  the  profession. 


We  have  been  agreeably  surprised  tofiud  the  vol- 
ume so  complete  in  regard  to  the  structure  and  func- 
tions of  the  nervous  system  in  all  Its  relations,  a 
subject  that,  in  many  respects,  is  one  of  the  most  diffi- 
cult of  all,  in  the  whole  range  of  physiology,  upon 
which  to  produce  a  full  and  satisfactory  treatise  of 
the  class  to  which  the  one  before  us  belongs.  The 
additions  by  the  American  editor  give  to  the  work  as 
it  is  a  considerable  value  beyond  that  of  the  last 
English  edition.  In  conclusion,  we  can  give  our  cor- 
dial recommendation  to  the  work  as  it  now  appears. 
The  editors  have,  with  their  additions  to  the  only 
work  on  physiology  in  our  language  that,  in  the  full- 
est sense  of  the  word,  is  the  production  of  a  philoso- 
pher as  well  as  a  physiologist,  brought  it  np  as  fully 
as  conld  be  expected,  if  not  desired,  to  the  standard 
of  our  knowledge  of  its  subject  at  the  present  day. 
It  will  deservedly  maintain  the  place  it  has  always 
had  in  the  favor  of  the  medical  profession. — Journ. 
of  Nervous  and  Mental  Dltease,  April,  1877. 

"Good  wine  needs  no  bush"  says  the  proverb,  and 
auold  and  faithful  servant  like  the  "big"  Carpenter,  as 
carefully  brought  down  as  this  edition  has  been  by  Mr. 
Henry  Power,  needs  little  or  no  commendation  by  us. 
Such  enormous  advances  have  recently  been  made  in 
our  physiological  knowledge,  that  what  was  perfectly 
new  a  year  or  two  ago,  looks  now  as  if  it  had  been  a 
received  and  established  fact  for  years.  In  this  ency- 
clopaedic way  it  is  unrivalled.  Here,  as  it  seems  to 
us,  is  the  great  value  of  the  book;  one  is  safe  in  sending 
a  student  to  it  for  information  on  almost  any  given 


subject,  perfectly  certain  of  the  fulness  of  information 
it  will  convey,  and  well  satisfied  of  the  accuracy  with 
which  it  will  there  be  found  stated. — London  Med. 
Times  and  Gazette,  Feb.  17, 1877. 

Thus  fully  are  treated  the  structure  and  functions  ol 
all  the  important  organs  of  the  body,  while  there  are 
chapters  on  sleep  and  somnambulism ;  chapterson  eth 
nology,  a  full  section  on  generalion.  and  abundant  re- 
ferences to  the  curiosiiies  of  physiology,  as  the  evolu 
tion  of  light,  heat,  electricity,  etc.     In  short,  this  new 
edition  of  Carpenter  is,  as  we  have  said  at  the  Ftnrt, 
a  very  encyclopedia  of  modern  physiology. — The  Glin- 
ic,  Feb.  24, 1877. 

The  merits  of  "  Carpenter's  Physiology"  are  so  widely 
known  and  appreciated  that  we  need  only  allude  briefly 
to  thefaot  that  in  the  latest  edition  will  be  found  a  com- 
prehensive embodiment  of  the  results  of  recent  physio 
lo<*ical  investigation.  Care  has  been  taken  to  preserve 
the  practical  character  of  the  original  work.  In  fact 
the  entire  work  has  been  brought  up  to  date,  and  bears 
evidence  of  the  amount  of  labor  that  has  been  bestow nd 
upon  it  by  its  distinguished  editor,  Mr.  Henry  Power. 
The  American  editor  has  made  the  latest  additions,  in 
order  fully  to  cover  the  time  that  has  elapsed  since  the 
last  English  edition. — N.  Y.  Me.d.  Journal,  Jan.  1877. 

A  more  thorough  work  on  physiology  could  not  be 
found.  In  this  all  the  facts  discovered  by  the  late  re- 
searches are  noticed,  and  neither  student  nor  practi- 
tioner should  be  without  this  exhaustive  treatise  on  au 
important  elementary  branch  of  medicine. — Atlanta 
Med.  and  Surg.  Journal,  Dec.  1876. 


(  WILLIAM  SENHOUSE),  M.D. 
A  MANUAL  OF  PHYSIOLOGY.    Edited  by  W.  MORRANT  BAKER, 

M.D.,  F.R.C.S.  A  new  American  from  the  eighth  and  improved  London  edition.  With 
about  two  hundred  and  fifty  illustrations.  In  one  large  and  handsome  royal  12mo.  vol- 
ume. Cloth,  $3  25;  leather,  $3  75.  (Lately  Issued.) 

Kirkes'  Physiology  has  long  been  known  as  a  concise  and  exceedingly  convenienttext-book, 
presenting  within  a  narrow  compass  all  that  is  important  for  the  student.  The  rapidity  with 
which  successive  editions  have  followed  each  other  in  England  has  enabled  the  editor  to  keep 
it  thoroughly  on  a  level  with  the  changes  and  new  discoveries  made  in  the  science,  and  the 
eighth  edition,  of  which  the  present  is  a  reprint,  has  appeared  so  recently  that  it  may  be  re- 
garded as  the  latest  accessible  exposition  of  the  subject. 


On  the  whole,  there  is  very  little  in  the  book 
which  either  the  student  or  practitioner  will  not  find 
of  practical  value  and  consistent  with  our  present 
knowledge  of  this  rapidly  changing  science;  and  we 
have  no  hesitation  in  expressing  our  opinion  that 
this  eighth  edition  is  one  of  the  best  handbooks  on 
physiology  which  wehaveinour  language. — N.  Y. 
Med  Record,  April  15,  1873. 

The   book  is  admirably  adapted  to  be  placed  in 


the    hands  of  stndenis. — Boston  Med.  and  Surg. 
Journ.,  April  10,  1873. 

In  its  enlarged  form  it  is,  in  ouropinion,  stil!  tie 
beat  book  on  physiology,  most  useful  to  thestudent. 
—Phila.  Med.  Times,  Aug.  30,  1873. 

This  is  undoubtedly  the  best  work  for  students  of 
physiology  extant.— Cincinnati  Med.  Newt,  Sept. 
1ST3. 


HEXRY  C.  LEA'S  PUBLICATIONS — (Physiology}. 


f}ALTON  (J.  C.),  M.D., 


X/ 


Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York.  <te. 

A  TREATISE  ON  HUMAN  PHYSIOLOGY.   Designed  for  the  use 

of  Students  and  Practitioners  of  Medicine.  Sixth  edition,  thoroughly  revised  and  enlarged, 
with  three  hundred  und  sixteen  illustrations  on  wood.    In  one  very  beautiful  octavo  vol- 
ume, of  over  800  pages.     Cloth,  $5  50  ;  leather,  $6  50.     (.Just  Issued.} 
Daring  the  past  few  years  several  new  works  on  phy-(      This  popular  text-book  on  physiology  conies  to  us  in 


sinlogy,  aud  new  editions  of  old  works,  have  appeared, 
competing  for  the  favor  of  the  medical  student,  but 
none  will  rival  this  new  edition  of  Dalton.  As  now  en- 
larged, it  will  be  found  also  to  be.  in  general,  a  satisfac- 
tory work  of  reference  for  the  practitioner. — Chieayo 
Mvl.  Journ.  and  Examiner,  Jan.  1 876. 

Prof.  Dalton  has  discussed  conflicting  theories  and 
conclusions  regarding  physiological  questions  with  a 
f;iirness,  a  fulness,  and  a  conciseness  which  lend  fresh- 
ness and  vigor  to  the  entire  book.  But  his  discussions 
have  been  so  guarded  by  a  refusal  of  admission  to  those 
speculative  and  theoretical  explanations,  which  at  best 
exist  in  the  minds  of  observers  themselves  as  only  pro- 
babilities, that  none  of  his  readers  need  be  led  into 
grave  errors  while  making  them  a  study. — The.  Medical 
Record,  Feb.  19, 1876. 

The  revision  of  this  great  work  has.brought  it  forward 
with  the  physiological  advances  of  theday.  and  renders 
it,  as  it  has  ever  been,  the  finest  work  for  students  ex- 
tant.— Nashville  Journ.  nf  Mtd.  and  Surg..  Jan.  1876. 

For  clearness  and  perspicuity,  Dalton's  Physiology 
commended  itself  to  the  student  years  ago.  and  was  a 
pleasant  relief  from  the  verbose  productions  which  it 
supplanted.  Physiology  has,  however,  made  many  ad- 
vances since  then— and  while  the  style  has  been  pre- 
served intact,  the  work  in  the  present  edition  has  been 
brought  up  fully  abreast  of  the  times.  Thenew  chemical 
notation  and  nomenclature  have  also  been  introduced 
into  the  present  edition.  Notwithstanding  the  multi- 
plicity of  text-books  on  physiology,  this  will  lose  none 
of  its  old  time  popularity.  The  mechanical  execution 
of  the  work  is  all  that  could  be  desired. — Peninsular 
Journal  of  Medicine,  Dec.  1875. 


its  sixth  edition  with  the  addition  of  about  fifty  percent, 
of  new  matter,  chiefly  in  the  departments  of  patho- 
logical chemistry  and  the  nervous  system,  where,  the 
principal  advances  have  been  realized.  With  so  tho- 
rough revision  and  additions,  that  keepthe  work  well 
up  to  the  times,  its  continued  popularity  may  be  confi- 
dently predicted,  notwithstanding  the  competition  it 
may  encounter.  The  publisher's  work  is  admirably 
done. — St.  Louis  Men.  and  Surg.  Journ  ,  Dec.  1875. 

We  heartily  welcome  this,  the  sixth  edition  of  this 
ad  mirable  text  book .  than  which  there  are  non  e  of equ  »1 
brevity  more  valuable.  It  iscordially  recommended  by 
the  Professorof  Physiology  in  the  University  of  Louisi- 
ana, as  by  all  competentteachersintheUnited  State?, 
and  wherever  the  English  language  is  read,  this  book 
has  been  appreciated.  The  present  edition,  with  its  31 6 
admirably  executed  illustrations,  has  been  carefully 
revised  and  very  much  enlarged,  although  its  bulk  does 
not  seem  perceptibly  increased. — New  Orleans  Medical 
and  Surgical  Journal,  March,  1876. 

The  present  edition  is  very  much  superior  to  every 
other,  not  only  in  that  it  brings  the  subject  up  to  the 
times,  but  that  it  do«s.so  more  fully  and  satisfactorily 
thananypreviousedition.  Takeitaltogt-therit  remains 
in  our  humble  opinion,  thebest  text  book  on  physiology 
in  any  land  or  language. —  The  Clinic.  Nov.  6, 1875. 

As  a  whole,  we  cordially  recommend  the  work  as  a 
text-book  for  the  student,  and  as  one  of  the  bpst. — 
The  Journal  oflfenmn  and  Mental  Disease,  Jan.  1876. 

Still  holds  its  position  as  a  masterpiece  of  lucid  writ- 
in?,  and  is,  we  believe,  on  the  whole,  the  best  book  to 
place  in  the  hands  of  the  student. —  London  Student? 
Journal. 


riUNGLISON  (ROBLEY\  M.D., 

•*^  Professor  of  Institutes  of  Medicine  in  Jefferson  Medical  fyllege,  Philadelphia. 

HUMAN  PHYSIOLOGY.  Eighth  edition.    Thoroughly  revised  and 

extensively  modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.   In  two 
large  and  handsomely  printed  octavo  volumes  of  about  1500  pages,  cloth,  $7  00. 

fJARTSHORNE  (HENRY),  M.D., 

-*-*  Professor  of  Hygiene,  etc  ,  in  the  Univ.  ofPtnna 

HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.     Second  Edi- 
tion., revised.    In  one  royal  12mo.  vol.,  with  220  wood  -cuts  :  cloth,  $1  75.     (Just  Issued.) 


[EHMANN(C.   #.). 

PHYSIOLOGICAL  CHEMISTRY.  Translated  from  the  second  edi- 
tion by  GEORGE  E.  DAT,  M.D.,  F.R.S.,  <tc.,  edited  by  R.  E.  ROGERS,  M  D  ,  Professor  of 
Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania,  with  illustratior  s 
selected  from  Funke's  Atlas  of  Physiological  Chemistry,  and  an  Appendix  of 
plete  in  two  large  and  handsome  octavo  volumes,  containing  1200  pages,  with  nearly  tv 
hundred  illustrations,  cloth,  $6  00. 

TOT  THE  SAME  AUTHOR.  ,    ,      ,   - 

°  MANUAL  OF  CHEMICAL  PHYSIOLOGY.    Translated  from  the 

German,  with  Notes  and  Additions,  by  J   CHBSTON  MORRTS,  M.D.,  with  an  Introductory 
Essay  on  Vital  Force,  by  Professor  SAKUEL  JACKSON,  M  D..  of  the  University  of  Penn 
gylvinia.     With  illustrations  on  wood.     In    one  very  handsome  octavo  volume  < 
p'ages.     Cloth,  $2  25.  _  __ 

ftEMSEN(lRA),  M.D.,  PJi.D., 

"*•*  Professor  of  Vhemixtry  in  the  Johns  Hopkin*  Unire^fity,  Baltimore. 

PRTNCIPLESOF  THEORETICAL  CHKMTSTRY.  with  special  reference 

to  the  Constitution  of  Chemical  Compounds.  In  one  handsome  royal  12mo.  vol.  of  over 
232  pages:  cloth,  $1  50.     (Just  Issued.) 


R  AND  FITTIG. 

OUTLINES  OF  ORGANIC  CHEMISTRY.    Translated  with  Ad- 

ditions from  the  Eighth  German  Ed.     By  IRA  REMSEN,  M  D     PhD     Prof,  of  Cbe,n. 
andPhysicsin  Williams  College,  Mass.  In  one  volume,  royal  12mo.of  550  pp.,  cloth,  *J. 


10 


HENRY  C.  LEA'S  PUBLICATIONS — (Che  mint 


ffO  WNES  (GEORGE),  Ph.D. 

-   A  MANUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and 

Practical.  Revised  and  corrected  by  HENRY  WATTS,  B.A.,  F  R.S.,  author  of  "A  Diction- 
ary of  Chemistry,"  etc.  With  a  colored  plnte,  and  one  hundred  and  seventy -seven  illus 
trationg.  A  new  American,  from  tbi  twelfth  mid  enlarged  London  edition.  Edited  by 
ROBERT  BRIDGES,  M.D.  In  one  large  royal  12mo.  volume,  of  over  1000  pages; 
cloth,  $2  75  ;  leather,  $3  25.  (Just  Ready) 

Two  careful  revisions  by  Mr.  Watts,  since  the  appearance  of  the  last  American  edition  of 
"  Fownes,"  have  so  enlarged  the  work  that  in  England  it  has  been  divided  into  two  volumes.  In 
reprinting  it,  by  the  use  of  a  stna'l  and  exceedingly  clear  type,  cast  for  the  purpose,  it  has  been 
found  possible  to  comprise  the  whole,  without  omission,  in  one  volume,  not  unhandy  for  study  and 
reference.  The  enlargement  of  the  work  has  induced  the  American  Editor  to  confine  his  additions 
to  the  narrowest  compass,  and  he  has  accordingly  inserted  only  such  discoveries  as  have  been  an  - 
nounced  since  the  very  recent  appearance  of  the  work  in  England,  and  has  added  the  standards 
in  popular  use  to  the  Decimal  and  Centigrade  systems  employed  in  the  original. 

Among  the  additions  to  this  edition  will  be  found  a  very  handsome  colored  plate,  representing 
a  number  of  spectra  in  the  spectroscope.  Every  care  has  been  taken  in  the  typographical  execu- 
tion to  render  the  volume  worthy  in  every  respect  of  its  high  reputation  and  extended  use,  and 
though  it  has  been  enlarged  by  more  than  one  hundred  and  fifty  pnges,  its  very  moderate  price 
will  still  maintain  it  as  one  of  the  cheapest  volumes  accessible  to  the  chemical  student. 


This  work,  inorganic  and  organic,  is  complete  in 
one  convenient  volume.  In  its  earliest  editions  it 
was  fully  up  to  the  latest  advancements  and  theo- 
ries of  that  time.  In  its  present  form,  it  presents, 
in  a  remarkably  convenient  and  satisfactory  man- 
ner, the  principles  and  leading  facts  of  the  chemistry 
of  to-day.  Concerning  the  manner  in  which  the 
various  subjects  are  treated,  much  deserves  to  be 
Kaid.and  mostly,  too,  in  praise  of  the  book.  A  re- 
view of  such  a  work  ae  Foumes's  Chemistry  within 
the  limits  of  a  book-notice  for  a  medical  weekly  is 
simply  out  of  the  question. — Cincinnati  Lancet  and 
Clinic,  Dec.  14, 1878. 

When  we  state  that,  5n  our  opinion,  the  present 
e  iition  sustains  in  every  respect  the  high  reputation 
which  its  predecessors  have  acquired  and  enjoyed, 
•we  express  therewith  our  fall  belief  in  its  intrinsic 
value  as  a  text-book  and  work  of  reference. — Am. 
Journ.  of  Pharm.,  Aug.  1878. 

The  conscientious  care  which  has  been  bestowed 
upon  it  by  the  American  and  English-editors  renders 
it  still,  perhaps,  the  best  book  for  the  student  and  the 
practitioner  who  would  keep  alive  the  acquisitions 
of  his  student  days.  It  has,  indeed,  reached  a  some- 


what formidable  magnitude  with  its  more  than  a 
thousand  pages,  but  with  less  than  this  no  fair  repre- 
sentation of  chemistry  as  it  now  is  can  be  given.  The 
type  is  small  but  very  clear,  and  the  section*  are  very 
lucidly  arranged  to  facilitate  study  and  reference. — 
MK&  and  Surg.  Reporter,  Aug  3,1878. 

The  work  is  too  well  known  to  American  students 
to  need  any  extended  notice;  sullice  it  to  say  that 
the  revision  by  the  English  editor  has  been  faithfully 
done,  and  that  Professor  Bridges  has  added  some 
fresh  and  valuable  matter,  especially  in  the  inor- 
ganic chemistry.  The  book  has  always  been  a  fa- 
vorite in  this  country,  and  in  its  new  shape  bids 
fair  to  retain  all  its  former  prestige. — Boston  Jour, 
of  Chemistry,  Aug.  1878. 

It  will  be  entirely  unnecessary  for  us  to  make  any 
remarks  relating  to  the  general  characterof  Fownes' 
Manual.  For  over  twenty  yearn  it  has  held  the  fore- 
most place  as  a  text-book,  aud  the  elaborate  and 
thorough  revisions  which  have  been  made  from  time 
to  time  leave  lit  tie  chance  for  any  wide  awake  rival  to 
step  before  it. — Canadian  Pharm.  Jour.,  Aug.  1878. 

As  a  manual  of  chemistry  it  is  without  a  superior 
in  the  language. — Md.  Med.  Jour.,  Aug.  1S78. 


flLASSEN  (ALEXANDER), 

Professor  in  the  Royal  Polj/technio  School,  Aix  la-Chapelle. 

ELEMENTARY    QUANTITATIVE   ANALYSIS.     Translated  with 

notes   and  additions  by  EDGAR  F.   SMITH,   Ph.D.,  Assistant  Prof,   of  Chemistry  in  the 
Towne  Scientific  School,  Univ.  of  Penna.     In  one  handsome  royal  12tno.  volume,  of  324 
pages,  with  illustrations;  cloth,  $2  00.     (Just  Ready.) 
A  smal',  practical,  comprehensive,  and  intelligible    nature  extant,  insomuch  as  its  methods  are  the  best. 


guide  to  practical  elementary  quantitative  analysis, 
and  U  particularly  adapted  to  the  wants  of  the  be- 
g'nner  with  laboratory  work. — If.  Y.  lied.  Record 
NJV.  12,  1878. 

It  ia  probably  the  best  manual  of  an  elementary 


It  teaches  by  examples,  commencing  with  single 
determinations,  followed  by  separations,  and  then 
advancing  to  the  analysis  of  minerals  and  such  pro- 
ducts as  are  met  with  in  applied  chemistry-  It  is 
an  indispensable  book  for  students  in  chemistry. — 
Boston  Journ.  of  Chemistry,  Oct.  1878. 


ftALLOWAY  (ROBERT],  F.C.S., 

Prof  of  Applied  Chemistry  in  the  Royal  Collrge  °f  Science  for  Ireland,  etc. 

A  MANUAL  OF  QUALITATIVE  ANALYSIS.  From  the  Fifth  Lon- 

don  Edition.    In  one  neat  royal  12mo.  volume,  with  illustrations  ;  cloth,  $2  75.     (Lately 
Issued.) 


We  regard  this  volume  as  a  valuable  addition  to 


the  chemical  text-books,  and  as  particularly  calcu 

lated  to  instruct  the  student  in  analytical  researches  I  Sapt.  1872. 

of  the  inorganic  compounds,  the  important  vegetable 


acid*,  and  of  compounds  and  various  secretions  and 
excretions  of  animal  orig.n.  —  Am.  Jour,  of  Pharm., 


DO  WMAN  (JOHN  E.} ,  M.D. 
INTRODUCTION  TO  PRACTICAL  CHEMISTRY,  INCLUDING 

ANALYSIS.  Sixth  American,  from  the  sixth  and  revised  London  edition.  With  numer- 
ous illustrations.     In  one  neat  vol.,  royal  12mo.,  cloth,  $2  25. 
JJY  THE  SAME  AUTHOR. 

PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.  In  one 

neat  volume,  royal  12mo.,  pp.  351,  with  numerous  illustrations;  cloth,  $2  25. 


HENRY  C.  LEA'S  PUBLICATIONS — (Chemistry). 


11 


A  TTFIELD  (JOHN),  Ph.D., 

•^*-  Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Great  Britain,  Ac. 

CHEMISTRY,  GENERAL,  MEDICAL,  AND  PHARMACEUTICA1  ; 

including  the  Chemistry  of  the  U.  8.  Pharmacopoeia.  A  Manual  of  the  General  Principles 
of  the  Science,  and  their  Application  to  Medicine  and  Pharmacy.  Eighth  edition  revised 
hy  the  author.  In  one  handsome  royal  12mo.  volume  of  700  pages,  with  illustration!?. 
Clotb,  $2  50  ;  leather,  $3  00.  (Just  Ready.) 

EXTRACT    FROM    THE    PREPACK. 

The  present,  Eighth,  edition  contains  such  alterations  and  additions  as  seemed  necessary  f <  r 
the  demonstration  of  the  latest  developments  of  chemiciil  principles  and  the  latest  applications 
of  chemistry  to  Pharmacy.  The  Author  has  bestowed  assiduous  labor  on  the  revision,  and 
the  extent  of  the  information  thus  introduced  may  be  estimated  from  the  fact  that  the  Index 
contains  three  hundred  new  references  relating  to  the  additional  material.  The  work  tow 
includes  the  whol«  of"  the  chemistry  of  the  United  States  Pharmacopoeia,  of  the  British  Pharma- 
copoeia, and  of  the  Pharmacopoeia  of  India. 

Engravirgs,  by  G.  Pearson,  Esq.,  of  most  of  the  important  pieces  of  apparatus  employed  in 
studying  chemistry  experimentally,  are  reproduced  in  this  Eighth  Edition.  The  twenty  micro- 
scopic views  are  after  drawings  by  Tufien  West,  Esq. 


DLOXAM  (C.  L.), 

-^-^  Professor  of  Chemistry  in  King's  College,  London. 

CHEMISTRY,  INORGANIC  AND  ORGANIC.    From  the  Second  Loi  - 

don  Edition.     In  one  very  handsome  octavo  volume,  of  700  pages,  with  about  300  illus- 
trations.    Cloth,  $4  00;  leather,  $5  00.     (Lately  Issued.) 

We  have  in  this  work  a  eompleteand  most  excel-  of  that  science  as  it  now  stands.  We  have  spoken 
lent  text-book  for  the  use  of  schools,  and  can  heart- ;  of  the  work  as  admirably  adapted  to  the  wants  of 
ily  recommend  it  as  such. — Boston  Med.and  Surg.  students  ;  it  is  quite  as  well  suited  to  the  require- 
J'turn.,  May  28,  1874.  i  ments  of  practitioners  who  wig-h  to  review  their 

'  chemistry,  or  have  occasion  to  refresh  their  memo- 

The  above  is  the  title  of  a  work  which  we  can  most  rieg  on  any  point  reiatjng  to  it.  In  a  word,  it  is  a 
OJoscientionsly  recommend  to  students  of  chemis-  !  book  to  be  -read  by  al]  who  wieh  to  knOW  what  ig 
try.  It  is  as  easy-asa  work  on  chemistry  could  be  j  the  chemistry  of  the  present  day.— American  Prac- 
made,  at  the  same  time  that  it  presents  a  fall  account  j  titioner,  Nov.  1873. 


(-1LO  WES  (FRANK).  D.Sc.,  London. 

Senior  Science-Master  at  the  High  School ,  Kewcastle-underlyme,  etc. 

AN  ELEMENTARY  TREATISE  ON  PRACTICAL  CHEMISTRY 

AND  QUALITATIVE  INORGANIC  ANALYSIS.  Specially  adapted  for  Use  in  the 
Laboratories  of  Schools  and  Colleges  and  by  Beginners.  From  the  Second  and  Revised 
English  Edition,  with  about  fifty  illustrations  on  wood.  In  one  very  handsome  royal 
12mo.  volume  of  372  pages:  cloth,  $2  50.  (Now  Ready.) 


It  is  short,  concise,  and  eminently  practical.  We 
therefore  heartily  commend  it  to  students,  an<i  e*pe- 
eially  to  those  who  are  obliged  to  dispense  with  » 
master.  Of  course,  a  teacher  is  in  every  way  desi- 
rable, but  a  good  degree  of  technicil  skill  and  prac- 
tical knowledge  can  be  attained  with  no  other 
instructor  than  the  very  valuable  handbook  now 
under  consideration. — St  Louis  Clin.  Record,  Oct. 

The  work  is  so  writfenand  arranged  that  it  can  be 
comprehended  by  the  student  without  a  teacher,  and 
the  descriptions  and  directions  forthe  various  work 


are  so  simple,  and  yet  concise,  as  to  be  interesting 
i  and   intelligible.     The  work  is  unincnmbered  with 
i  theoretical    deductions,  dealing    wholly    with    the 
'  practical  matter,  which  it  is  the  a  m  of  this  compre- 
j  hensive  text-book  to  impart.     The  accuracy  of  the 
|  analytical  methods  are  vouched  f>>r  from  the  fact 
that  they  have  all  been  worked  through  by   the 
author    and   the   members,  of  his  c  asv  from   the 
printed  text.   We  can  heartily  recommend  the  woik 
to  the  student  of  chemistry  as  being  a  reliable  at  d 
comprehensive  one. — Druggists'  Advertiser,  Oct. 
15.  1877. 


KNAPP'S  TECHNOLOGY;  or  Chemistry  Applied  to 
the  Arts,  and  to  Manufactures.  With  American 
additions  by  Prof.  WALTER  R.  JOHNSON.  In  two 


very  handsome  octavo  volumes,  with  500  woe  d 
engravings,  cloth,  $6  00. 


TjlARQUHARSON  (ROBERT),  M.D., 

•*•  Lecturer  on  Materia  tfedica  at  St.  Mary's  Hospital  Medical  School. 

A  GUIDE  TO  THERAPEUTICS  AND  MATERIA  MEDICA.     Ed- 
ited, with  Additions,  embracing  the  U.  S.  Pharmacopoeia.  By  FRAXK  WOODBURIT,  M.D. 
In  one  neat  rojal  12mo.  volume  of  over  400  pages  :  cloth,  $2.     (Just  Ifsned.) 
Manv  persons  who   learned   therapeutics  before  ;  it  straight  across  the  page,  we  at  once  perceive  the 
the pnv-ioloeical  action  of  remedies  was  taught  to  \  relations  of  the  one  to  the  other.   On  this  account,  the 
student find  ,t  difficult  to  discover  the  bearing  of  \  work  is  likely  to  be  useful,  not  on  y  to  students  p. e- 
phTsiolWieal    action    oa    therapeutic    employment  !  paring  for  their  examinations,  bn    to  those ,medi 
from ordinary  text-books.   Dr.  Farqubarson  has  most     men,   also,   who  are   well  acquainted   with   larger 
inwni.ms?y  shown  it  by  printing  the  two  in  parallel    books  on  the  same  subject,  but  experience  the  diffl- 
columns  and  corresponding  p*,a,-ra .hs,  so  that,  by     culty,  already  mentioned     of   see.ng   the    relation, 
running  the  eye  down  the  left-hand  side  of  a  page  we    between   the  .ciionti  and   n,e  of  remedies.  -  Tht 
get  the  physiological  actions  of  a  drug,  and  on  the  !  London  Practitioner,  January,  18/8. 
right-hand  the  therapeutical  uses,  while,  by  running  i 


12      HENRY  C.  LEA'S  PUBLICATIONS — (Mat.  Med.  and  Therapeutics). 


&ARR1SH  (EDWARD), 

Late  Professor  of  Materia  Medico,  in  the  Philadelphia  College  of  Pharmacy. 

A  TREATISE  ON  PHARMACY.    Designed  as  a  Text-Book  for  the 

Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  Formulae  an<l 
Prescriptions.  Fourth  Edition,  thoroughly  revised,  by  THOMAS  S.  WIKGAND.  In  one 
handsome  octavo  volume  of  977  pages,  with  280  illustrations;  cloth,  $5  50  ;  leather,  $6  50. 
(Lately  Issued.) 


Of  T)r.  Parrish's  great  work  on  pharmacy  it  only 
remains  to  be  said  that  the  editor  has  accomplished 
his  work  so  well  as  to  maintain,  in  this  fourth  edi- 


the  work,  not  only  to  pharmacists,  but  also  to  the 
multitude  of  medical  practitioners  who  are  obliged 
to  compound  (heir  own  medicines.  It  will  ever  hold 


tion,  the  high  standard  of  excellence  which  it  bad  !  an  honored  place  on  our  own  bookshelves. — Dublin 
attained  in  previous  editions,  under  the  editorship  of|  Med.  Press  and  Circular,  Aug.  12,  1874. 
its  accomplished  author.    This  has  not  been  accom-  | 
pllshed  without  much  labor, and  many  additions  and 


improvements,  involving  changes  in  the  arrange- 


We  expressed  our  opinion  of  a  former  edition  in 


terms  of  unqualified  praise,  and  we  are  in  no  mood 


meutdf  the  several  parts  of  the  work,  and  the  addi-    to  delr*c}  fror"  that  op\ulo»  in  reference  to  the  pre- 
tion  of  much  new  matter.    With  the  modifications    sent  edition,  the  preparation  of  which  has  fallen  into 


thus  effected  it  constitutes,  as  now  presented,  a  com- 
pendium of  the  science  and  art  indispensable  to  the 
pharmacist,  and  of  the  utmost  value  to  every 
practitioner  of  medicine  desirous  of  familiarizing 
himself  with  the  pharmaceutical  preparation  of  the 
articles  which  he  prescribes  for  his  patients. — Chi- 
cago Med.  Journ.,  July,  1874. 

The  work  is  eminently  practical,  and  has  the  rare 
merit  of  being  readable  and  interest  ing,  while  it  pre- 


cora  pete  nt  bauds.  It  is  a  book  with  which  no  pharma- 
cist can  dispense,  and  from  which  no  physician  can 
fail  to  derive  much  information  of  value  to  him  in 
practice. — Pacific  Med.  and  Surg.  Journ.,  June, '74. 

Perhaps  one.ifnotthe  most  important  book  upon 
pharmacy  which  has  appeared  in  the  English  lan- 
guage has  emanated  from  the  transatlantic  press. 
"Parrish's  Pharmacy"  is  a  well-known  work  on  this 
side  of  the  water,  and  the  fact  shows  ns  that  arealiy 


serves  a  strictly  scientific  character.  The  whole  work  :  useful  work  never  becomes  merely  local  in  its  fame, 
reflects  the  greatest  credit  on  author,  editor  and  pub-  i  Thanks  to  the  judicious  editing  of  Mr.  Wiegand,  the 
lisher.  Itwillconveysomeideaoftheliberality  which  '  posthumous  edition  of  "Parrish"  has  been  saved  to 
has  been  bestowed  upon  its  production  when  we  men-  the  public  with  all  the  mature  experience  of  its  an- 
tion  that  there  are  no  less  than  280 carefully  executed  thor.  and  perhaps  none  the  worse  for  a  dash  of  new 
illustrations.  In  conclusion,  we  heartily  recommend  '  blood. — Land.  Pharm.  Journal,  Oct.  17,  1874. 


J3TILLE  (ALFRED],  M.D., 

Professor  of  Theory  and  Practice  of  Medicine  in  the  University  of  Penna. 

THERAPEUTICS  AND  MATERIA  MEDICA ;  a  Systematic  Treatise 

on  the  Action  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History. 
Fourth  edition,  revised  and  enlarged.  In  two  large  and  handsome  8vo.  vols.  of  about  2000 
pages.  Cloth,  $10;  leather,  $12.  (Lately  Issued.) 


It  is  unnecessary  to  do  much  more  than  to  an- 
nounce the  appearance  of  the  fourth  edition  of  this 
well  known  and  excellent  work.— Brit,  and  For. 
Med.-Chir.  Review,  Oct  Ib75. 

For  all  who  desire  a  complete  work  on  therapeutics 
and  materia  medica  for  reference,  in  cases  involving 
medico-legal  questions,  as  well  as  for  information 
concerning  remedial  agents,  Dr.  Still^'s  is  "par  ex- 
cellence" the  work.  The  work  tveingout  of  print, by 
the  exhaustion  of  former  editions,  the  author  has  laid 
the  profession  under  renewed  obligations,  by  the 
careful  revision,  importantadditions,  and  timely  re 
issuing  a  work  not  exactly  supplemented  by  any 
other  in  the  English  language,  if  in  any  language. 
The  mechanical  execution  handsomely  sustains  the 
well-known  skill  and  good  taste  of  the  publisher. — 
St.  Louis  Med.  and  Surg.  Journal,  Dec  1874. 

From  the  publication  of  the  first  edition  "Still6's 
Therapeutics"  has  been  one  of  the  classics;  its  ab- 
sence from  our  libraries  would  create  a  vacuum 
which  could  be  filled  by  no  other  work  in  the  lan- 
guage, and  its  presence  supplies,  in  the  two  volumes 


of  the  present  edition,  a  whole  cyclopaedia  of  thera- 
peutics.— Chicago  Medical  Journal,  Veto.  1875. 

The  rapid  exhaustion  of  three  editions  and  the  uni- 
versal favor  with  which  the  work  has  been  received 
by  the  medical  profestion,  are  sufficient  proof  of  its 
excellence  as  a  repertory  of  practical  and  useful  in- 
formation for  the  physician.  The  edition  before  us 
fully  sustains  this  verdict, a s  the  work  has  been  care- 
fully revised  and  in  some  portions  rewritten,  bring- 
ing it  up  to  the  present  time  by  the  admission  of 
chloral  and  croton-chloral.  nitrite  of  amyl.  bichlo- 
ride of  methylene,  methylic  ether,  lithium  com- 
pounds, gelseminnm,  and  other  remedies. — Am. 
Journ.  of  Pharmacy,  Feb.  1S75. 

We  can  hardly  admit  that  it  has  a  rival  in  the 
multitude  of  its  citations  aiid  the  fulness  of  its  re- 
search into  clinical  histories,  and  we  must  assign  it 
a  place  in  the  physician's  library;  not,  indeed,  as 
fully  representing  the  present  slate  of  knowledge  in 
pharmacodynamics,  but  asbyfarthe  most  complete 
treatise  upon  the  clinical  and  practical  side  of  the 
question. — Boston Mtd.  and.  Surg.  Journal,  Nov.f, 


/GRIFFITH  (ROBERT  E.),  M.D. 

A  UNIVERSAL  FORMULARY,  Containing  the  Methods  of  Prepar- 
ing and  Administering  Officinal  and  other  Medicines.  The  whole  adapted  to  Physiciars  and 
Pharmaceutists.  Third  edition,  thoroughly  revised,  with  numerous  additions,  bj  JOUM  M. 
MA.ISCH,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large 
and  handsome  octavo  volume  of  about  800  pp.,  cl.,  $450  ;  leather,  $5  50.  (Lately  Issued.) 


To  the  druggist  a  good  formulary  is  simply  indis 
pensable,  and  perhaps  no  formulary  has  been  more 
extensively  used  than  the  well-known  work  before 
us.  Many  physicians  have  to  officiate,  also,  as  drug- 
gists. This  is  true  especially  of  the  country  physi- 
cian, and  a  work  which  shall  teach  him  the  means 
by  which  to  administer  or  combine  his  remedies  in 
the  most  efficacious  and  pleasant  manner,  will  al- 
ways hold  Its  place  upon  his  shelf.  A  formulary  of, 
thin  kind  is  of  benefit  also  to  the  city  physician  in  i 
largest  practice.— Cincinnati  dtinic,  Feb.  21,  1874. 1 


A  more  complete  formulary  than  ills  in  its  pres- 
ent form  the  pharmacist  or  physician  could  hardly 
desire.  To  the  first  some  such  work  is  indispensa- 
ble, and  it  is  hardly  less  essential  to  the  practitioner 
who  compounds  his  own  medicines.  Much  of  what 
is  contained  in  the  introduction  ought  to  be  com- 
mitted to  memory  by  every  student  of  medicine. 
As  a  help  to  physicians  it  will  be  found  invaluable, 
and  doubtless  will  make  its  way  into  libraries  not 
already  supplied  with  a  standard  work  of  the  kind. 
—The  American  Practitioner,  Louisville,  July,  '74. 


HENRY  C.  LEA'S  PUBLICATIONS — (Mat.  Med.and  Therapeutics).      13 
UTILLE  (ALFRED],  M.f),  LL.D.,  and  JITAISCH  (JOHN  M.).  Ph.D., 

*J        Pro/,  of  Theory  and  Practice  of  Medicine  -L'-*-        Pr.,f.  of.Vut.  3fed.  and  S,,t   in  Phi/a, 

and  of  Clinical  Med.  in  Univ.  of  Pa.  Coll.  Pharmacy.  S"cy  to  t he  American 

Pharmaceutical  Association. 

THE   NATIONAL  DISPENSATORY :  Containing  the  Natural  History, 

Chemistry,  Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recognized  in 
the  Pharmacopoeias  of  the  United  Stntes  and  Great  Britain.  In  one  very  handsome 
octavo  volume  of  T628  pages,  with  over  200  illustrations.  Extra  cloth,  $6  75  ;  leather, 
raised  bands,  $7  50.  (Now  Ready.) 

.   EXTRACT  FROM  THE  PREFACE. 

"  In  the  rapid  progress  of  modern  research,  few  subjects  have  of  late  years  received  greater  acces- 
sions of  facts  than  the  group  of  sciences  connected  with  materia  niedica  and  therapeutics.  The 
new  resources  thus  placed  at  the  command  of  the  pharmaceutist  and  physician  have  seemed  to  the 
authors  to  justify  an  attempt  to  make,  frum  the  advanced  stand-point  of  the  present  day,  a  concise 
but  complete  statement  of  all  that  is  of  practical  importance  to  both  professions — a  digest  in  which 
that  which  is  old  and  that  which  is  new  shall  be  so  brought  together  as  to  give  to  the  reader,  within 
the  most  moderate  practicable  compass,  all  the  details  in  pharmacology,  pharmacy,  and  thera 
peuties,  which  he  is  likely  to  need  in  his  daily  avocations.  In  the  almost  infinite  accumulation  of 
material,  this  has  required  a  careful  and  conscientious  sifting  to  discard  that  which  is  obsolete, 
untrustworthy,  or  comparatively  trivial,  without  impairing  the  practical  completeness  of  the 
work.  That  they  have  wholly  accomplished  their  object  the  authors  do  not  venture  to  claim  ;  but 
they  can  say  that  years  of  constant  labor  have  been  devoted  to  the  task  of  producing  a  work  to 
which  the  inquirer  may  refer  with  the  certainty  of  finding  everything  which  experience  has  stored 
up  as  worthy  of  confidence  in  the  subjects  embraced  within  its  scope." 

From   ACSTIX  FLINT,  M.D.,  Prof,  of  Principles  and  j  the  respect  and  attention  due  to  authority.     The 

Practice  of  Med.  in  Bellevue  Hosp.  Med.  Coll.,     "raison  d'etre"  of  the  book  is  modestly  stated  in 

N.  Y.  the  preface,  and  now  that  it  has  been  published  and 

The  Dispensatory  fills  a  vacuum  in  medical  lite-     0Peas  to  us  its  vast  stores  of  information,  we  may 

rature  which  has  long  existed      Of  its  large  and  j  add  that  il  was  almost  a  necessity  ;  and  this  we  say 

long  circulation  there  can  be  no  doubt.  without  meaning  to  impugn  the  great  excellence  of 

|  the  works  of  similar  character  which  have  preceded 

From  ROBERT  T.  EDES,  Prof,  of  Materia  Medica  In    it.     All  of  the  descriptions,  whether  medical,  botaii- 

ical,  or  pharmaceutical,  are  clear,  in  good  English, 


Med.  Dept.  Harvard  Univ. 

It  seems  worthy  of  the  high  reputation  of  the  au- 
thors, and  likely  to  fulfil  the  expectations  with 
which-we  have  anticipated  its  coming.  The  accu- 
racy and  value  of  its  statements  are  of  course  as- 
sured by  the  names  of  the  authors,  and  I  am  very 
favorably  impressed  with  the  method  of  arrange- 
ment as  likely  to  facilitate  reference,  a  point  of 
great  importance  in  a  work  of  this  class.  I  am  par- 
ticularly pleased  with  the  brief  and  forcible  but  yet 
careful  and  judicious  statements  of  the  therapeutic 
value  (and.  what  is  quite  as  important, want  of  value) 
of  the  various  drugs  treated  of. 

This  is  a  most  magnificent  work,  with  its  over  six- 
teen hundred  closely  printed  pages  and  two  hundred 
illustrations.  As  should  be  in  a  Dispensatory,  the 
alphabetical  order  of  arrangement  has  been  adopted 
throughout.  But  it  would  require  several  pages  of 
the  Medical  News  for  ns  to  give  even  briefly  a  de- 
scription of  the  work.  Prof.  Stille's  work  on  Mate;ia 
Medica  and  Therapeutics  has  ever  since  its  publica- 
tion been  a  standard  work  on  those  subjects,  and 
this  fact  alone  is  certainly  a  guarautee  of  his  quali- 
fications for  the  important  work  of  producing  a  Dis- 
pensatory ;  and  as  regards  Professor  Maisch,  his 
high  standing  as  a  chemist  and  pharmaceutist  is 
well  known.  We  would  probably  make  an  impor- 
tant omission  in  our  brief  notice  of  the  work,  if  we 
failed  to  draw  attention  to  a  feature  quite  novel  in  a 
Dispensatory,  namely,  the  possession  of  a  Thera- 
peutical Index.  By  reference  to  it  the  physician 
can  see  at  a  glance  the  remedies  usually  employed 
in  any  disease.  The  Index  of  Materia  Medica  covers 
fifty-five  triple  columned  pages,  and  contains  about 
10,400  references.  The  Therapeutical  Index  occupies 
thirty-three  double  columned  pages,  and  contains 
about  3750  references.  —  Cincinnati  Med.  Hews, 
March,  1879. 

The  present  Dispensatory  is  arranged  in  alpha- 
betical order  from  the  commencement,  the  recent 
fcdvauces  in  chemistry  are  mentioned,  and  an  effort 
made  to  include  the  late  novelties  in  the  review  of 
the  resources  of  the  physician.  This  is  carried  out 
with  that  sound  conservative  judgment  which  cha- 
racterizes all  Prof.  Stille's  work.  The  chemical 
and  pharmaceutical  sections  have,  we  may  suppose, 
received  the  especial  care  of  Prof.  Maisch;  and  as 


and  unencumbered  with  obsolete  and  unintelligible 
terms.  Those  portions  which  have  reference  to 
therapeutics  form  a  convenient  treatise  on  that  sub- 
ject, and  are  made  the  more  valuable  and  available 
by  a  complete  therapeutical  index.  The  purely 
pharmacal  part  is  as  perfect  as  it  is  possible  to  make 
it,  and  less  could  not  have  been  expected  when  we 
consider  Prof.  Maisch 's  great  qualifications  for  work 
of  that  kind.— A".  C  Med.  Jou.ru.,  March,  1879. 

The  therapeutic  part  Is  as  rich  as  would  be  ex- 
pected of  the  author  of  the  most  comprehensive  work 
on  the  subject  in  our  language.  The  physiological 
effects  of  drugs  receive  due  attention,  and  their  iu- 
Sueuce  over  disease  is  stated  succinctly.  For  the 
task  of  winnowing  the  immense  accumulation  of 
periodical  literature,  the  experience  and  matured 
judgment  of  Prof.  Still6  were  eminenlly  fitted.  No 
pharmacist  or  doctor  will  repent  the  purchase  of  a 
book  which  is  at  once  a  treasury  of  facts  and  the 
digest  of  a  decision  of  a  high  court.  —Louinville  Med. 
Ifews,  March  29, 1879. 

The  pharmaceutical  world  has  for  a  long  time 
been  ou  the  qui  vive,  in  expectation  of  the  forthcom- 
ing Dispensatory  by  Profs.  Stille  and  Maisch,  who 
have  acquired  tuch  a  reputation  in  their  respective 
Departments  that  nothing  but  a  satisfactory  work 
could  be  expected  ;  this  expectation  has  been  quite 
realized.  We  have  examined  the  work  with  some 
care,  and  are  very  much  pleased  that  we  can  pro- 
nounce it  to  be  reliable,  comprehensive,  and  includ- 
ing the  latest  re*earches  available  to  its  authors. 
This  is  more  particularly  true  as  regards  the  portion 
devoted  to  pharmaceutical  subjects.  We  are  fully 
justified  in  stating  that  it  is,  taken  altogether,  one 
of  the  most  important  and  creditable  publications 
which  have  of  late  been  issued  by  the  American 
press.  It  will  be  an  indispensable  reference  book 
both  for  the  pharmacist  and  the  physician.—  JVtia 
Remedies,  April,  1879. 

A  careful  examination  of  the  work  calls  forth  un- 
qualified praise  for  its  excellent  arrangement,  fnll 
yet  concice  information,  its  careful  adherence  to  the 
best  authority  on  each  particular  topic,  as  well  as 
the  entire  elimination  of  all  unnecessary  and  obso- 
lete data  and  particulars.  The  arrangement  of  all 
topics  is  purely  alphabetical,  and  with  surprising 


he  is  futile  princepgin  that  branch,  nothing  can  be  i  fidelity  to  the  wants  both  of  the  physician  and  phar- 


said  of  them  except  in  praise. — Med.  and  Surg.  Re- 
porter  April  5,  1879. 

It  has  been  prepared  by  two  gentlemen  whose 


maceutist.  New  remedies  which  have  come  into 
recent  use  are  here  found  noticed,  with  such  facts 
as  have  been  collated  from  careful  investigation.— 


learning  fully  qualified  them  for  the  difficult  task,  j  Druggist^  Circular  and  Chemical  Gazette,  Mareh, 
and  whose  eminence  entitles  them  to  be  heard  with  1 1379. 


14 


HENRY  C.  LEA'S  PUBLICATIONS—  (Pathology,  &c.). 


(F.),  AND  T2ANVIER  (£,.), 

v>'         Pro/,  in  £A«  Faculty  of  Med  ,  Paris.  Prof  in  the  College  of  Prance. 

MANUAL  OF  PATHOLOGICAL  HISTOLOGY.     Translated,  with 

Notes  and  Additions,  by  E.  0.  SHAKESPEARE,  M.D.,  Pathologist  and  Ophthalmic  Surgeon 
to  Pbiluda.  Hospital,  Lecturer  on  Refrcction  and  Operative  Ophthalmic  Surgery  in  Univ. 
of  Penna.  In  one  very  handsome  octavo  volume  of  about  6CO  pages,  with  over  300  illus- 
trations. (Preparing.) 

So  much  has  been  done  of  late  years  in  the  elucidation  of  pathology  by  means  of  the  micro- 
scope, and  this  subject  now  occupies  so  proininenta  position  ns  one  of  the  most  important  branches 
of  medical  science,  that  the  American  profession  cannot  fail  to  welcome  a  truncation  of  the  pre- 
sent work,  wnich,  through  its  own  merits  find  through  the  well-known  reputation  of  its  distin- 
guished authors,  is  regarded  in  Europe  as  the  standard  text-book  and  work  of  reference  in  its 
department.  Such  investigations  and  discoveries  as  have  been  made  since  its  appenrance  will  be 
introduced  by  the  translator,  nn<l  the  work  is  confidently  expected  to  assume  in  this  country  the 
game  position  which  has  been  go  universally  accorded  to  it  abroad. 


(SAMUEL],  M.D., 

Aftittant  Physician  to  the  London  ffogpital, 

THE  STUDENT'S  GUIDE  TO  MEDICAL  DIAGNOSIS.    From  the 

Third  Kevised  and  Enlarged  English  Edition.     With   eighty-four  illustrations  on  wood. 

In  one  very  handsome  volume,  royal  12mo.,  cloth,  $2  25.     (Just  Issued.) 

are  few  books  of  thissizeon  practical  medicine  that 
containsomuchandconveyit  so  well  as  the  volume 
before  us.  It  is  a  book  we  can  sincerely  recommend 
to  the  student  for  direct  instruction,  and  to  the]prac- 
titioner  as  a  ready  and  useful  aid  to  his  memory.— 
Am.  Journ.  of  Syphilography,  Jan.  1874. 


Of  the  many  gnida-books  on  medical  diagnosis, 
cUimed  to  be  written  for  the  special  instruction  of 
students,  thie  is  the  best.  Theauthoris  evidently  a 
well-read  and  accomplished  physician. and  he  knows 
how  to  teach  practical  medicine.  The  charm  of  sim- 
plicity Is  not  the  least  interesting  feature  in  the  man- 
nar  in  which  Dr.  Fen w  ick conveys  instruction.  There 


SCREEN  (T.  HENRY],  M.D., 

Lecturer  on  Pathology  and  Morbid  Anatomy  at  Qharing-droiis  Hospital  Medical  School,  etc. 

PATHOLOGY  AND  MORBID  ANATOMY.    Third  American, from 

the  Fourth  and  Enlarged  and  Revised  English  Edition.     In  one  very  handsome  octavo 
volume  of  332  pages,  with  132  illustrations;  cloth,  $2  25.     (Just  Ready.) 

This  is  unquestionably  one  of  the  best  manuals  on  i  ciently  numerous,  and  usual  y  well  made.  In  the 
the  subject  of  pathology  and  morbid  anatomy  that  present  edition,  such  new  matter  has  been  added  as 
can  be  placed  in  the  student's  hands,  and  we  are  was  necessary  to  embrace  the  later  results  in  patho- 
glad  to  see  it  kept  up  to  the  times  by  new  editions,  logical  research.  No  doubt  it  will  continue  to  eujoy 
Each  edition  is  carefully  revised  by  the  author,  with  the  favor  it  has  received  at  the  hands  of  the  protes- 


the  view  of  making  it  include  the  most  recent  ad- 
vances in  pathology,  and  of  omitting  whatever  may 
have  become  obsolete. — A".  Y.  Med.  Jour.,  Feb.  1879. 


sion.— Med  and  tiurg.  Reporter,  Feb.  1,  1879. 

For  practical,  ordinary  daily  n*e,  this  is  undoubt- 
edly the  best  treatise  that  is  offered  to  fctndeUg  of 


The  treatise  of  Dr.  Green  i«  compact,  clearly  ex-  ;  pathology  and  morbid  anatomy. — Cincinnati  Lan- 
pressf  d,  up  to  the  times,  and  popular  as  a  text-book,    at  and  Clinic,  Feb.  8,  1S79. 
both  in  England  and  America.    The  cuts  are  suffl-  ! 


D 


AVIS  (NATHAN  S.], 

Prof,  of  Principles  and  Practice  of  Medicine,  etc.,  in  Chicago  Med.  College. 

CLINICAL  LECTURES  ON  VARIOUS  IMPORTANT  DISEASES; 

being  acollection  of  the  Clinical  Lectures  delivered  in  the  Medical  Wards  of  Mercy  Hos- 
pital, Chicago.  Edited  by  FRANK  H.  DAVIS,  M.D.  -Second  edition,  enlarged.  In  one 
handsome  royal  12mo.  volume.  Cloth,  $175.  (Lately  Issued.) 


WHAT  TO  OBSERVE  AT  THE  BEDSIDE  AND  AFTER 
DEATH  IN  MEDICAL  CASES.  From  the  second  Lon- 
don edition.  1  vol  royal  12mo.,  cloth.  $100. 

CH  RISTISON'S  DISPENSATORY.  With  copious  ad- 
ditions, and  213  large  wood-engravings,  by  K. 
E«ILESPIBLI>GRIFFITH,  M.D.  One  vol.Svo.,  pp.  HOO. 
cloth.  $400. 

CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  CF 
ALCOHOLIC  LIQUORS  IK  HEALTH  AMD  DISEASE.  Ne* 
edition,  with  a  Preface  by  D.  F.  COKDIB,  M.D.,  atd 
explanations  of  scientific  wordr.  In  oneneatJ2mr. 
volume,  pp.  178.  cloth.  60  cents. 

OLUGE'S  ATLAS  op  PATHOLOGICAL  HISTOLOGY 
Translated,  with  Notes  and  Additions,  by  JOSEPH 
LKIDT,  M.  D.  In  one  volume,  very  large  imperial 
qnarto,  with  320  copper-plate  figures,  plain  and 
colored,  cloth.  t*00. 

LA  ROCHE  ON  TBLLOW  FEVER. considered  in  Its 
Historical,  Pathological,  Etiological,  and  Thera 
peutical  Relations.  In  two  large  and  handsome 
octavo  volumes  of  nearly  IflOO  pp  ,  cloth.  $7  00. 

HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. 1  vol.  8vo.,  pp.  600,  cloth.  $3  50. 


BARLOW'S  MANUAL  OF  THK  PRACTICE  OF 
MEDICINE.  With  Additions  by  D.  F.  COKDIF, 
M  D.  1  vol.  8vo.,  pp.  600,  cloth.  $2  50. 

TODD'SCLINICAL  LECTURES  on  CERTAIN  ACUTE 
DISEASES.  In  one  neat  octavo  volume,  of  320  pp  , 
•loth.  $2  50. 

STURGES'S  INTRODUCTION  TO  THE  STUDY  OF 
CLINICAL  MEDICINE.  Being  a  Guide  to  the  In- 
vestigation of  Disease.  In  one  handsome  12mo. 
volume,  cloth,  $1  2.5.  (Lately  Insued.) 

STOKES'  LECTURES  ON  FEVER.  Edited  by  JOHH 
WILLIAM  MOORE,  M.D. ,  Assistant  Physician  to  the 
Cork  Street  Fever  Hospital.  In  one  neat  Sro. 
volume,  cloth,  $2  00.  (Just  Issued.) 

THE  CYCLOPAEDIA  OF  PRACTICAL  MEDICINE: 
comprising  Treatises  on  the  Nature  and  Treatment 
of  Diseases,  Materia  Medica  and  Therapeutic*,  Dis- 
eases of  Women  and  Children,  Medical  Jurispru- 
dence, etc.  etc.  By  DUNGLISOS,  FORBTS,  TWEEDIE, 
and  CONOLLY.  In  four  large  super  royal  octavo 
volumes,  of  3254  double  columned  p  ige-s  strongly 
and  handsomely  bound  in  leather,  $15;  cloth,  $11. 


HENRY  C.  LEA'S  PUBLICATIONS — (Practice  of  Medicine}. 


15 


ffLINT  (A  UST1N),  M.D., 

•*•  Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Med.  College,  N.  7. 

A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE  OF 

MEDICINE  ;  designed  for  the  use  of  Students  and  Practitioners  of  Medicine.  Fourth 
edition,  revised  and  enlarged.  In  one  large  and  closely  printed  octavo  volume  of  about 
1 100  pp. ;  cloth,  $6  00  ;  or  strongly  bound  in  leather,  with  raised  bands,  $7  00.  (Lately 
Issued. ) 

By  common  consent  of  the  English  and  American  medical  press,  this  work  has  been  assigned 
to  the  highest  position  as  a  complete  and  compendious  text-book  on  the  most  advanced  condi- 
tion of  medical  science.  At  the  very  moderate  price  at  which  it  is  offered  it  will  be  found  one 
of  the  cheapest  volumes  now  before  the  profession. 


This  excellent  treatise  on  medicine  lias  acquired 
for  itself  in  the  United  States  a  reputation  similar  to 
that  enjoyed  in  England  by  the  admirable  lectures 
of  Sir  Thomas  Watson.  It  may  not  possess  the  same 
charm  of  style,  but  it  has  like  solidity,  the  fruit  of 
long  and  patient  observation. and  presents  kindred 
moderation  and  eclecticism.  We  have  referred  to 
many  of  the  most  important  chapters,  and  find  there 
vision  spoken  of  in  the  preface  is  a  genuine  one,  and 
that  the  author  has  very  fairly  brought  up  hi  f  matter 
to  the  level  of  the  knowledge  of  the  present  day.  The 
work  has  this  great  recommendation,  that  it  is  in  one 
volume,  and  therefore  will  not  be  so  terrifying  to  the 
student  as  the  bulky  volumes  which  several  of  our 
English  text-books  of  medicine  have  developed  in  to. 
—  British  and  Foreign  Jled.-Chir.  Rev.,  Jan.  187£. 

It  is  of  course  unnecessary  to  introduce  or  eulogize 
this  now  standard  treatise.  All  the  colleges  recom 


in  which  one  of  its  editions  is  not  to  be  found.  Tie 
present  edition  has  been  enlarged  and  revised  to 
bring  it  up  to  the  author's  present  level  of  experi- 
ence and  reading.  His  own  clinical  stndiesand  the 
latest  contributions  to  medical  literature  both  in 
thic  country  and  in  Europe,  have  received  careful 
attention,  to  that  some  portions  have  been  entirely 
rewritten,  and  about  seventy  pages  of  new  matter 


havebeen  added.  —  Cnicngo 


Jovr.,  June,  1873. 


Has  never  been  surpassed  as  a  text-book  for  stu- 
dents and  a  book  of  ready  reference  for  practition- 
ers TheforeB  of  its  logic,  its  simple  and  practical 
teachings,  have  left  it  without  a  rival  in  the  field. 
N.  Y.—Med  Record,.  Sept.  15,  1874. 

It  is  given  to  very  few  men  to  tread  in  the  steps  of 
Austin  Flint,  whose  single  volume  on  medicine, 
though  here  and  there  defective,  is  a  masterpiece  of 
lucid  condensation  and  of  general  grasp  of  an  enor- 


mend  it  as  a  text-book,  and  there  are  few  libraries    monsly  widesubject  — Land.  Practitioner, Dec. '78. 


C 


C 


THE  SAME  AUTHOR. 

CLINICAL  MEDICINE;   a  Systematic  Treatise  on    the  Diagnosis 

and  Treatment  of  Diseases.  Designed  for  Students  and  Practitioners  of  Medicine.  In 
one  large  and  handsome  octavo  volume.  (In  Prtss  ) 

THE  SAME  A  UTHOR. 

ESSAYS    ON    CONSERVATIVE   MEDICINE    AND    KINDRED 

TOPICS.     In  one  very  handsome  rojal  12mo.  volume.     Cloth,  $1  38.     (Just  Issued.) 

WOODBVRT  (FRANK),  M.D  , 

Physician  to  the  German  Bvipitnl,  Philadelphia,  late  Physician  to  the  Out-patient  Department 
of  t  hi  Jeff.  College  Hospital,  etc. 

A    HANDBOOK   OF   THE   PRINCIPLES  AND    PRACTICE   OF 

Medicine  ;  for  the  use  of  Students  and  Practitioners.  Based  upon  Husband's  Handbook 
of  Practice.  In  one  neat  volume,  rpyal  12mo.  (In  Frets.) 

fJA  R  TSHORNE  (  HENR  Y),  M.  D., 

•*•-*•  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

ESSENTIALS  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEI  I- 

CINE.  A  handy-book  forStudents  and  Practitioners.  Fourth  edition,  revised  and  im- 
proved. With  about  one  hundred  illustrations.  In  one  hand&ome  royal  12mo  volume, 
of  about  550  pages,  cloth,  $2  63  ;  half  bound,  $2  88.  (Lately  Issued.) 


As  ahandbook,  which  clearly  sets  forth  the  ESSEN- 
TIALS Of  the  PRINCIPLES  AND  PRACTICE  Of  MEDICINE, 

we  do  not  know  of  its  equal.—  Va.  Mtd.  Monthly. 
As  a  brief,  condensed,  but  comprehensive  hand- 


book, it  cannot  be  improved  upon. — Chicago  lied. 
Examiner,  Nov.  15,  1874 

Without  doubt  the  best  book  of  the  kind  published 
in  the  Enjzlixh  language.— St.  Louis  Med. and  Surg. 
Journ.,  Nov.  1874. 


TXTATSON  (THOMAS],  M.D.,  frc. 

LECTURES    ON    THE     PRINCIPLES    AND    PRACTICE    OF 

PHYSIC.  Delivered  at  King's  College,  London.  A  new  American,  from  the  Fifth  re- 
vised and  enlarged  English  edition.  Edited,  with  additions,  and  several  hundred  illustra- 
tions, by  HENRY  HARTSHORKE,  M.D.,  Professor  of  Hygiene  in  the  University  of  Penn- 
sylvania. In  two  large  and  handsome  Svo.vols.  Cloth,  $9  00;  leather,  $11  00.  (Lately 
Publisfied.) 

^It  is  a  subject  for  congratulation  and  for  thank-  cate  and  important  pathological  and  practical  ques- 
ful  less  that  Sir  Thomas  Watson,  during  a  period  of  |  lions,  the  results  of  his  clear  insight  and  his  calm 
comparative  leisure,  after  a  long,  laborious,  and  [judgment  are  now  recorded  for  the  benefit  of  man- 
most  honorableprofessional  career,  while  retaining  >  kind,  in  language  which,  for  precision,  vigor,  and 
full  possession  of  his  high  mental  faculties,  should  j  classical  elegance,  has  rarely  been  equalled,  and 
have  employed  the  opportunity  to  submit  his  Lee-  |  never  surpassed  The  revision  has  evidently  been 
tures  to  a  more  thorough  re  vision  than  wa  possible  j  most  carefully  done,  and  the  results  appear  in  al- 
daring  the  earlier  and  busier  period  of  his  life,  most  every  page.—  Brit.  Med.  Joum.,  Oct.  14,  1871. 
Carefully  passing  in  review  some  of  the  most  intri-  i 


16 


HENRY  C.  LEA'S  PUBLICATIONS — (Practice  of  Medicine}. 


JDRISTOWE  (JOHN  SYER],  M.D.,  F.R.C.P., 

J-)  Phytician  and  Joint  Lecturer  on  Medicine.,  St.  Thomax'g  FTntpital. 

A  MANUAL  ON  THE  PRACTICE  OP  MEDICINE..  Edited,  with 

Additions,  by  JAMES  II.  Ilu-  CHINSON,  M.D.,  Physician  to  the  Penna.  Hospital.    In  one 
handsome  octavo  volume  of  over  1100  pages  :  cloth,  $5  50  ;  leather,  $6  50.    (Jmt  Issued.) 


This  portly  volume  Is  a  model  of  condensation. 
In  a  stylo  at  once  clear,  interesting, and  concise,  Dr. 
Bristowe  passes  in  review  every  conceivable  subject 
connected  with  the  practice  of  medicine.  Those 
practitioners  who  purchase  few  books  will  find  this 
a  mof  t  opportune  publication,  because  to  many  top- 
ic* not  usually  embraced  in  a  work  on  practice  are 
adequately  handled.  The  book  is  a  thoroughly  g'»od 
one,  and  its  usefulness  to  American  readers  has  been 


increased  by   the  judicious   notes  of  the  Editor. — 
Cincinnati  Clinic,  Jan   7,  1877. 

Anyone  who  wants  a  good,  clear,  condensed  work 
upon  Practice,  quite  np  with  the  most  recent  views  in 
pathology,  will  find  this  a  most  valuable  work  The 
additions  made  by  Dr.  Hutchinson  are  appropifate 
and  useful,  and  so  well  done  that  we  wir-h  there  were 
more  of  them. — Am.  Practitioner,  Feb.  1&77. 


the  Principles  and  Practice  of  Medicine  at  Guy's 


fJABER'SHON  (S.  0.).  M.D. 

-*--*-  Senior  Physician  to  and  late  Lecturer  on 

Hospital,  etc. 

ON  THE  DISEASES  OF  THE  ABDOMEN,  COMPRISING  THOSE 

of  the  Stomach,  and  other  parts  of  the  Alimentary  Canal,  (Esophagus,  Caecum,  Intes- 
tines, and  Peritoneum.  Second  American,  from  the  third  enlarged  and  revised  Eng- 
lish edition.  With  illustrations.  In  one  handsome  octavo  volume  of  over  500  pages. 
Cloth,  $3  50.  (Now  Ready.) 

This  work  has  remained  sime  time  out  of  print,  owing  to  the  careful  and  conscientious 
revision  which  it  has  enjoyed  at  the  hands  of  the  author,  and  which  has  nearly  doubled  its 
size  since  the  appearance  of  the  first  edition.  Yet  there  is  no  work  accessible  to  the  profession 
to  take  its  place,  as  a  careful,  practical  guide  on  a  class  of  diseases,  which  form  so  large  and 
important  a  portion  of  the  duties  of  the  physician,  and  for  which  the  author's  position  has 
given  him  almost  unequalled  opportunities  for  observation  and  experience.  The  very  extensive 
scope  of  the  volume  will  be  seen  by  the  subjoined  condensed 
SUMMARY  OF  CONTENTS. 

Chapter  I.  Introduction.  II.  On  Diseases  of  the  Tongue  and  Mouth.  III.  On  Diseases  of 
the  Pharynx.  IV.  On  diseases  of  the  (Esophagus.  V.  On  Organic  Diseases  of  the  Stomach. 
VI.  On  Functional  Diseases  of  the  Stomach.  VII.  On  Diseases  of  the  Duodenum  VIII. 
On  Muco-Enteritis  and  Enteritis.  IX.  On  Strutnous  and  Tubercular  Disease  of  the  Alimen- 
tary Canal;  Lardaceous  Disease.  X.  On  Diseases  of  the  Caecum  and  Appendix  Casci.  XI. 
On  Diarrhoea.  XII.  On  Dysentery  and  Catarrhal  Inflammation  of  the  Colon.  XLII.  On 
Typhoid  Disease  of  the  Intestine.  XIV.  On  Colic.  XV.  On  Constipation.  XVI.  On  Organic 
Obstruction,  Internal  Strangulation,  Intussusception,  and  Carcinoma  of  Intestine.  XVII. 
On  Suppurntion  of  the  Abdominal  Parietes,  Perforation  of  the  Intestine  from  without,  and 
Abscess  of  the  Abdominal  Parietes  extending  into  the  Intestine;  Fecal  Abscess.  XVIII. 
On  intestinal  Worms.  XIX.  On  Peritonitis.  XX.  On  Aecites,  Dropsy.  XXI.  On  Abdomi- 
nal Tumors. 

amended  by  the  author.  Several  new  chapter*  have 
been  added,  bringing  the  work  fully  up  to  the  times, 
and  making  it  a  volume  of  interest  to  the  practitioner 
in  every  field  of  medicine  and  surgery.  Perverted 
nutrition  is  in  some  form  associated  with  all  diseases 
we  have  to  combat,  and  we  need  all'  the  light  that 
can  be  obtained  on  a  subject  so  broad  and  general. 
Dr  Haber«hon's  work  is  one  that  every  practili  'cer 
should  read  and  study  for  himself.— JV.  Y.  Mtd. 
Journ.,  April,  1879. 


This  valuable  treatise  on  diseases  of  the  stomach 
and  abdon.cn  has  been  out  of  print  for  several  years, 
and  is  therefore  not  so  well  known  to  the  profession 
as  it  deserves  to  be.  It  will  be  found  a  cyclopaedia 
of  information,  systematically  arranged,  on  all  dis- 
eases of  the  alimentary  tract,  from  the  mouth  to  the 
rectum.  A  fair  proportion  of  each  chapter  Is  devot- 
ed to  symptoms,  pathology,  and  therapeutics.  The 
present  edition  is  fuller  man  former  ones  in  many 
particulars,  and  has  been  thoroughly  revised  and 


ffOTHERGILL  (J.  MILNER},M.D.  Edin.,  M.R.C.P.  Lond., 

-*-  Agst.  Phys.  to  the  West  Lond.  Hogp. ;  Asst.  Phys.  to  the  City  of  Lond.  Ho*p. ,  etc. 

THE  PRACTITIONER'S  HANDBOOK  OF  TREATMENT;  Or,  the 

Principles  of  Therapeutics.     In  one  very  neat  octavo  volume  of  about  550  pages  :  cloth, 

$4  00.     (Now  Ready.) 

one  of  those  books  which  both  deserve  and  are  likely  to 
survive.  This  book,  although  written  ostensibly  for  the 
young  and  inexperienced,  may  be  very  profitably  studied 
by  those  who  have  been  practicing  their  profession 
more  or  less  empirically  for  thirty  or  forty  years.  We 
content  ourselves  with  again  recommending  the  book 
very  cordially. — Edin.  Med.  Journ.,  Jan.  1677. 

We  heartily  commend  bis  bock  to  tbemedical  student 
as  an  honest  and  intelligent  guide  through  the  mazes  of 
therapeutics,  and  assure  the  practitioner  who  has  grown 
gray  in  the  harness  that  he  will  derive  pleasure  and  in- 
struction from  its  perusal.  Valuable  suggestions  and 
material  for  thought  abound  throughout.—  BoslonMed. 
and  Surg  Journal,  Mar.  8, 1877. 


Our  friend*  will  find  this  a  very  readable  book ;  and 
that  it  sheds  light  upon  every  theme  it  touches, causing 
the  practitioner  to  feel  more  certain  of  his  diagnosis  in 
difficult  cases.  We  confidently  commend  the  work  to 
our  readers  as  one  worthy  of  careful  perusal.  It  lighis 
the  way  over  obscure  and  difficult  passes  in  medical 
practice.  The  chapter  on  the  circulation  of  the  blood 
is  the  most  exhaustive  and  instructive  to  be  found.  It 
la  a  book  every  practitioner  nerds,  and  would  have,  if 
he  knew  how  suggestive  and  helpful  it  would  be  to 
him.—  St.  Louis  MfJd.  and  Surg.  Journ ,  April,  1877. 

It  is  our  honest  conviction,  after  a  careful  perusal  of 
this  goodly  octavo,  that  it  represents  a  great  amount  of 
earnest  thought  and  painstaking  work,  and  is  therefore 


•DT  THE  SAME  AUTHOR. 

THE  ANTAGONISM  OF  THERAPEUTIC  AGENTS,  AND  WHAT 

IT  TEACHES.    Being  the  Fothergillinn  Prize  Essay  for  1878.    In  one  neat  volume,  royal 
12mo.  of  156  pages;  cloth,  $1  00.      (Just  Ready.) 

It  will  be  found  a  highly  interesting  study  and  I  certain    drugs.—  Medical  and    Surgical  Reporter, 
practical  application  of  the  antagonistic  action   of  1  Sept.  14,  187s. 


HENRY  C.  LEA'S  PUBLICATIONS — ^Practice  of  Medicine). 


17 


plXLA  YSON  (JAMES),  M.D., 

Physician  and  Lecturer  on  (Clinical  Mefli"ine  in  fh°  Glasgow  We.xtf.rn  Infirmary,  eta. 

CLINICAL    DIAGNOSIS;    A    Handbook    for    Students   and    Prnc- 

titioners  of  Medicine.     In  one  handsome  12mo.  volume,  of  546  pages,  with  85  illustra- 
tions.    Cloth,  $2  63.      (Just  Ready.) 

The  concurrence  of  gentlemen  specially  familiar  with  the  several  subjects  being  requisite  to 
the  satisfactory  development  of  a  plan  so  extensive,  Dr.  Finlaygon  has  secured  the  co-operation 
of  Prof.  Gairdner,  who  has  contributed  the  chapter  on  the  Physiognomy  of  Disease;  Prof.  \Vm. 
Stephenson  that  on  Disorders  of  the  Female  Organs ;  Dr.  Alex.  Robertson  that  on  Insanity ; 
Prof.  Samson  Gemmell  those  on  the  Sphygmograph  and  Physical  Diagnosis ;  and  Dr.  Joseph 
Coates  those  on  the  Fauces,  Larynx,  and  Nares,  and  on  the  method  of  performing  post-mortem 
examinations.  Other  chapters  have  enjoyed  the  advantage  of  revision  by  gentlemen  specially 
versed  in  their  several  subjects  ;  and  the  volume  is  presented  as  thoroughly  on  a  level  with 
the  most  advanced  condition  of  knowledge  in  a  department  which  has  made  such  rapid  strides 
of  advancement  within  the  last  few  years. 

The  hook  is  an  excellent  one,  clear,  concise,  con  ve-  This  is  one  of  the  really  useful  books.  It  is  attrac- 
nient,  practical.  It  is  replete  with  the  very  know-  j  live  from  pr-face  to  the  final  page,  and  ought  to  be 
ledge  the  student  needs  when  he  quits  the  lecture-  ;  given  a  place  on  every  office  table,  because  it  contains 
room  and  the  laboratory  for  the  ward  and  sick-room,  ,  in  a  condensed  form  all  that  is  valuable  in  semeiology 
and  does  not  lack  in  information  that  will  meet  the  ;  and  diagnostics  to  be  found  in  bulkier  volumes,  and 
wants  of  experienced  and  older  men. — Phila.  Med.  '.  because  in  its  arrangement  and  complete  index,  it  is 
Times,  Jan.  4,  1879.  I  unusually  convenient  for  qnick  reference  in  any 

The  aim  of  the  author  is  to  teach  a  student  and  !  emergency  that  may  come  upon  the  busy  practitioner, 
practitioner  how  to  examine  a  case  so  as  to  n-e  "all  ,  —**•  "•  Med-  Journ.,  Jan.  1879. 

his  knowledge''  in  arriving  at  a  diagnosis.  All  the  i  This  is  a  most  important  work  for  students,  and 
various  symptoms  of  the  several  systems  are  grouped  one  that  is  d>  stined  to  become  rapidly  popular.  It 
together  in  such  a  manner  as  to  mike  their  relations  is  composed  of  contributions  from  various  eminent 
to  a  final  diagnosis  clear  and  easy  pf  apprehension.  ,  sources  bearing  upon  this  subject.  The  real  secret 
This  work  has  been  done  by  men  of  large  experience  •  of  successful  practice  is  the  accurate  diagnosis  of 
and  trained  observation,  who  have  been  long  recog-  ,  disease.  This  manual  teaches  the  student  to  arrange 
nized  as  authorities  upon  the  subjects  which  they  i  his  investigation  in  such  system  as  to  enable  him, 
treat.  There  is  a  profusion  of  illustrations  to  illns-  !  with  practice,  to  acquire  this  very  desirable  faculty, 
trate  subjects  under  discussion.  The  application  of  (  The  division  of  the  subject,  as  iu  this  work,  among 
electricity,  and  instruments  of  precision  in  diagnosis,  i  the  highest  authorities  living,  is  a  good  idea,  and 
is  fully  discussed.  This  book  is  all  good.  We  com- j  gives  us  in  one  compact  form  a  series  of  monographs 


mend  it  to  all  students  and  practitioners  of  medicine 
as  a  work  worthy  of  a  place  in  their  libraries. —Ohio 
Med.  Recorder,  Dec.  1878. 


written  by  masters. — Nashville  Journal  of  Med. 
and  Surg.,  Jan.  1879. 


TJAM1LTOX  (ALLAN  McLANE),  M.D., 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlackwelVs  Island,  N.  7., 
and  at  the  Out- Tatients'  Department,  of  the  New  York  Hospital. 

NERVOUSDISBASESjTHEIR  DESCRIPTION  AND  TREATMENT. 

In  one  handsome  octavo  volume  of  512  pages,  with  53  illus. ;  cloth,  $3  50.     (Just  Ready.) 


This  is  unquestionably  the  best  and  most  com- 
plete text-book  of  nervous  diseases  that  has  yet  ap- 
peared, and  were  international  jealousy  in  scientific 
affairs  at  all  possible,  we  might  be  excused  for  a 
feeling  of  chagrin  that  it  should  be  o'f  American 
parentage.  This  work,  however,  has  been  performed 
in  New  York,  and  has  been  so  well  performed  that 
no  room  is  left  for  anything  but  commendation. 
With  great  skill,  Dr.  Hamilton  has  presented  to  his 
readers  a  succinct  and  lucid  survey  of  all  that  is 
known  of  the  pathology  of  the  nervous  system, 
viewed  in  the  light  of  the  most  recent  researches. 
From  the  preliminary  description  of  the  methods  of 
examination  and  study,  and  of  the  instruments  of 
precision  employed  in  the  investigation  of  nervous 
diseases,  up  till  the  final  collection  of  formulfe,  the 
book  is  eminently  practical. —.Brain,  London,  Oct. 
1878. 

The  author  tells  ns  in  his  preface  that  it  has  been 
his  object  to  produce  a  concise,  practical  book,  and 
we  think  he  has  been  successful,  considering  the  ex- 
tent of  the  subject  which  he  has  undertaken.  In 
fact,  it  is  more  extensive  than  the  title  properly  or 
accurately  indicates,  embracing — besides  what  are 
usually  regarded  as  nervous  diseases — inflammatory 
affections,  both  acute  and  chronic,  hemorrhages  and 
tumors  of  the  cerebrum  and  cerebellum,  medulla 
oblongata,  spinal  cord  and  nerves,  with  thrombosis 
and  embolism  of  the  arteries,  sinuses,  and  reins. 
The  reader  may  therefore  expect  information,  more 
or  less  full  and  satisfactory,  on  almost  every  point 


connected  with  the  nervous  system.  We  have  no 
hesitation  in  saying  that  reliance  may  be  placed  on 
Dr.  Hamilton's  conscientious  performance  ot'  his  self- 
assigned  task,  on  his  soundness  of  judgment,  and 
freedom  from  empiricism. — Edinburgh  Med.  Journ., 
Oct.  1878. 

From  a  very  careful  examination  of  the  whole 
work,  we  can  justly  say  that  the  author  has  not  only 
clearly  and  fully  treated  of  diagnosis  and  treatment, 
but,  unlike  most  works  of  this  class,  it  is  very  com- 
prehensive in  regard  to  etiology,  and  exposes  the 
pathology  of  nervous  diseases  in  the  light  of  the  very 
latest  experiments  and  discoveries.  The  drawings 
are  excellent  and  well  selected.  After  this  careful 
revision,  we  can  heartily  recommeud  this  work  to 
students  and  general  practitioners  in  particular  as 
being  a  full  exposition  of  diseases  of  the  nervous  sys- 
tem, their  pathology  and  treatment,  to  date.— JV.  Y. 
Med.  Record,  Aug.  3,  1878. 

As  stated  in  the  preface,  the  author's  object  has 
been  to  write  a  concise  and  practical  book,  for 
which  there  is  certainly  a  place,  and  we  think  he 
has  succeeded  admirably  in  fulfilling  his  object. 
The  usual  plan  is  adopted  in  the  classification  of 
the  different  diseases,  the  book  not  being  greatly 
unlike  Hammond's  in  this  respect,  although  it  is 
very  noticeable  throughout  that  the  author's  opin- 
ions vary  widely  from  those  of  Dr  Hammond. — Am. 
Supp.  Obstet.  Sourn.  Great  Britain  and  Ireland, 
July,  1878. 


riHARCOT  (J.  M.), 

Professor  to  the  Faculty  of  Med.  Paris,  Phys.  to  La  Salpetriere,  etc. 

LECTURES  ON  DISEASES  OF  THE  NERVOUS  SYSTEM.  Trans- 
lated from  the  Second  Edition  by  GEORGE  SIGERSO*.  M.D.,  M.Ch.,  Lecturer  OB  Biology, 
etc.,  Cnth.  Univ.  of  Ireland.  With  illustrations.  (Publishing  in  the  Medical  News  and 
Library,  commencing  with  the  July  No.  1878  See  page  2  ) 


18        HKNRY  C.  LEA'S  PUBLICATIONS — {Diseases  of  the  Chest, 


'DROWN  (LENNOX],  F.R.C.S.  Ed., 

Senior  Surgeon  to  the  Central  London  Throat  find  Ear  Hwpltal,  etc., 

THE  THROAT   AND  ITS  DISEASES.     With  one  hundred  Typical 

Illustrations  in  colors,  and  fifty  wood  engraving?,  designed  nnd  executed  by  the  author. 
In  one  very  handsome  imperial  octavo  volume  of  351  pages;  cloth,  $5  00.   (Now  Ready.) 


The  author'*  rare  artistic  skill  hns  been  utilized 
In  the  production  of  one  hundred  beautiful  illustra- 
tions iu  colors,  the  very  best  of  the  kind  we  have 
seen,  and  which  have  been  distributed  in  ten  plates. 
Fifty  wood  engravings,  designed  and  executed  by 
the  author,  appear  in  the  body  of  the  work — these 


are  unusually  accurate.  In  conclusion,  we  recom- 
mend this  beautiful  volume  an  a.o  acceptable  addi- 
tion to  the  library  of  those  engaged  ic  the  treatment 
of  diseases  of  the  throat. — N.  Y.  Med,  Record.  Nov. 
9,  1S78. 


&E1LKR  (CAUL),  M.D., 

*~J  Lecturer  on  LarynposC'py  at  the  Univ.  of  Fenna  ,   Chief  of  the  Throat  Dispeniary  at  the 

Univ.  Hospital,  Phila  ,  etc. 

HANDBOOK  OF  DIAGNOSIS  AND  TREATMENT  OF  DISEASES  OF 

THE    THROAT   AND    NASAL   CAVITIES.      In  one  handsome  royal  12mo.  volume. 
With  illustrations.      (In  Press.) 


PLINT  (AUSTIN],  M.D., 

Professor  of  the  Principles  and  Praottct  of  Medicine  in  Bellevue  Hospital  Jfed.  College,  N.  Y. 

PHTHISIS:  ITS  MORBID  ANATOMY,  ETIOLOGY,  SYMPTOM- 
ATIC EVENTS  AND  COMPLICATIONS,  FATALITY  AND  PROGNOSIS,  TREAT- 
MENT, AND  PHYSICAL  DIAGNOSIS;  in  a  series  of  Clinical  Studies.  By  AUSTIN 
FLINT,  M.D.,  Prof,  of  the  Principles  and  Practice  of  Medicine  in  Bellevue  Hospital  Med. 
College,  New  York.  In  one  handsome  octavo  volume  :  $3  50.  (Lately  Issued.) 


This  book  contains  an  analysis,  in  the  author's  lucid 
F/yle,  of  the  notes  whirh  lie  has  made  in  several  hun- 
dred cases  in  hospital  and  private  practice.  We  com- 


mend the  book  to  the  perusal  ot  all  interested  in  the 
<tudy  of  :bN  disease. — Huston  Med.  and  Surg.  Journal, 
Feb.  10,  18T6. 


DY   THE  SAME   AUTHOR. 

A  MANUAL  OF  PERCUSSION  AND  AUSCULTATION;  of  the 

Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.    In 
one  handsome  royal  12mo.  volume:  cloth,  $1  75.     (Just  Issued.) 


B 


Y  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS,  PATHOLOGY, 

AND  TREATMENT  OF  DISEASES  OF  THE  HEART.     Second  revised  and  enlarged 
edition.     In  one  octavo  volume  of  550  pages,  with  a  plate,  cloth,  $4. 
Dr.  Flint  chose  a  difficult  subject  for  his  researches    »nd  clearest  practical  treatise  on  those  subjects,  and 


ind  has  shown  remarkable  powers  of  observation 
in  \  reflection,  as  well  as  great  industry,  in  his  treat- 
ment of  it.  His  book  must  be  considered  the  fullest 


should  be  in  the  hands  of  all  practitioners  and  stu- 
lents  It  is  a  credit  to  American  medical  literature. 
— Amer.  Journ.  of  the  Med.  Sciences,  July,  1860. 


75  F  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  .THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING  THE 
RESPIRATORY  ORGANS.  Second  and  revised  edition.  In  one  handsome  octavo  volume 
of  595  pages,  cloth,  $4  50. 


WILLIAMS'S  PULMONARY  CONSUMPTION;  its 
Nature,  Varieties,  and  Treatment.  Wilh  an  An- 
alysis of  One  Thousand  Cases  to  exemplify  its 
duration.  In  one  neat  octavo  volume  of  about 
350  pages;  cloth,  $2  50. 

DIPHTHERIA  ;  its  Nature  and  Treatment,  with  an 
account  of  the  History  of  its  Prevalence  in  vari- 
ous Countries.  By  D.  D.  SI.ADE,  M.D.  Second  and 
revised  edition.  In  one  neatroyal  12mo.  volume, 
cloth,  $1  25. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART  AND 
GREAT  VESSELS.  Third  American  Edition.  In 
1  vol.  Svo.,  420  pp.,  cloth,  $3  00. 

LECTURES  ON  THE  DISEASES  «F  THE  STOMACH. 
With  an  Introduction  on  its  Anatomy  and  Physio- 
logy. By  WILLIAM  BRJNTON,  MD.,  F.R.S  From 
the  second  and  enlarged  London  edition.  With  il- 
lustrations on  wood.  In  one  handsome  octavo 
volume  of  about  300  pages:  cloth,  $3  24. 

LA  BOCHB  OK  PNEUMONIA.  1  vol.  8vo.,  cloth. 
of  500  page*.  Price,  tS  00. 

LINCOLN'S  ELECTROTHERAPEUTICS;  a  Concise 
Manual  of  Medical  Electricity.  In  one  very  neat 
royal  12mo.  volume,  cloth,  with  Illustrations, 
ftl  50. 

CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 
NERVOUS  DISORDERS  By  0.  H  ANPFIEI.D  JONK?, 
M.D.,  Physician  to  St.  Mary's  Hospital,  &c.  Sec 
oti'l  American  Edition.  In  one  handsome  octavo 
Toluute  of  348  pages,  cloth,  $3  25. 


FULLER  ON  DISEASES  OF  THE  LUNGS  AND  AIR- 
PASSAGES.  Their  Pathology,  Physical  Diagnosis, 
Symptoms,  and  Treatment.  From  the  second  and 
revised  English  edition.  In  one  handsome  ocatvo 
volume  of  about  500  pages  :  cloth,  $3  50. 

CHAMBERS'S  MANUAL  OF  DIET  AND  REGIMEN 
IN  HEALTH  AND  SICKNEsS.  la  one  handsjine 
octavo  volume.  Cloth,  ijS'2  7."> 

CHAMBERS'S  RESTORATIVE  MEDICINE.  An  Har- 
veian  Annual  Oration.  With  Two  Sequels.  In 
one  very  handsome  vol.  small  12ino  ,  cloth,  $1  00. 

PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  hand- 
some volume,  small  octavo,  cloth,  $2  00. 

PAVY'S  TREATISE  ON  FOOD  AND  DIETETICS. 
Physiologically  and  Therapeutically  Considered. 
In  one  handsome  octavo  volume  of  nearly  600 
pages,  cloth,  $4  75. 

S  vlITH  ON  CONSUMPTION  ;  ITS  EARLY  AND  RE- 
MSDIABLE  STAGES.  1  vol.  Svo. .  pp.  254  *2  2-'. 

BASHAM  ON  RENAL  DISEASES:  a  Clinical  Guide 
to  their  Diagnosis  and  Treatment.  With  Illustra- 
tions In  one  I2mo.  vol.  of  304  page?,  cloth,  $2  00. 

LECTURES  ON  THE  STUDY  OF  FEVER.  By  A. 
HcDStix,  M.D..  M.R.I. A.,  Physician  to  the  ileath 
Hospital.  In  one  vol.  8vo.,  cloth,  $2  50. 

A  TREATISE  ON  FEVER.  By  ROBKBT  D.  LYOHC, 
KCC.  Inoneoctavo  volume  of  362  pages,  cloth, 
$2  25. 


-~(  VenerealDigeases,  Ac.).         1  9 


R 


UMSTEAD  (FREEMAN  J.)    MD 

mTT^T™7  Venereal  DietaSeS  aithg  °°1'  °*  'Ph»*   nnd  *«'*-  »™  Tor*.  AC 

EASES  TH,°JJO(JY  AND   TREATMENT  OF  VENEREAL  DIB- 

Cn        "  °f  ™-mi  investigation"  "P™  the  subject.    Third  editicn, 

1  one  large  and  hand°om°  octavo 


'  the  auth°r  has  8UbJeoted  "  to  *  very 
rewritten'  a°d  much  new  matter  added,  in  order  to 

fu      ompon  oftK    t  .         ™0.'*  ad™n°«d  condition  of  syphilography,  but  by  care- 

page        /he  labor  thn,  h    f  "T^"  ^I*'?11?'  th°  W°rk  ha8  been  increase*  by  only  sixty-four 

Son  asa  comnl«J»    H6S*      t     T*   ^'^  ''  h°ped'  wilHn««"  for  "  »  continuance  of  its 
complete  and  trustworthy  guide  for  the  practitioner. 


le  work  on  Venere 

Widft    f*i  ron  1  a  H  *        t  v 

been  accep'ted  as  the  staudard'but  ap  pears 'tThave 
formed  tl.e  basis,  to  a  large  extent,  of  many  of  the 
^^^f*™^  >!«ve  b^n  wrUtenyon  the 
England.- 


n_I,VVrfe-m^t0,0mplelebookwith  which  weareae- 
qnainted  in  the  language.  The  latest  views  of  the 

ist  authontiesareput  forward,  and  the  information 
Is  well  arranged-a  great  point  for  the  student  and 

HI  more  for  the  practitioner.  The  subjects  of  vix- 
seral  syphilis,  syphilitic  affections  of  theeyes,  and 
the  treatment  of  syphilis  by  repeated  inoculations, 
are  rery  fully  diseussed.— Land.  Lancet,  Jan.  7,  71. 

Dr.  Bumstead's  work  is  already  go  universally 
Known  as  the  best  treatise  in  the  English  language  on 


ranereal  diseases,  that  it  may  seem  almost  superflu- 
ous to  say  more  of  it  than  that  a  new  edition  ha*  been 
issued.  But  the  author's  Industry  has  rendered  thig 
new  edition  virtually  a  new  work,  and  so  merits  as 
much  special  commendation  as  if  its  predecessors 
hac  not  been  published.  As  a  thoroughly  practical 
book  on  a  class  of  diseases  which  form  a  large 
share  of  nearly  every  physician's  practice,  the  vol- 
ume beforf  us  is  by  far  the  best  of  which  we  have 
knowledge .—tf.  T.  Medical  Gatetts,  Jan.  28,  1871. 

It  Is  rare  in  the  history  of  medicine  to  find  anyone 
book  which  contains  all  that  a  practitioner  needs  t  o 
know;  while  the  possessor  of  "Bnnmead  on  Vene- 
real" has  no  occasion  to  look  outside  of  Us  covers  for 
anything  practical  connected  with  the  diagnosis,  his- 
tory, or  treatment  of  th«se  affections.— N.  T.  Itedi- 
""  Journal,  March,  1871. 


nULLERIEE  (A.},  and 

^        Surgeon  to  the  Hdvital  du  Midi. 


J1DMSTEAD  (FREEMAN  J.), 

-LJ       Profesior  of  Venerea  I  IHttaseg  in  the  College  oj 
Phyaitrianii  and  Surgeong.  N.  T 


AN  ATLAS  OF  VENEREAL  DISEASES.  Translated  and  Edited  by 

FBKKMAN  J.  BUMSTBAD.  In  one  large  imperial  4to.  volume  of  328  pages,  double-columns. 

with  26  plates,  containing  about  150  figures,  beautifully  colored,  many  of  them  the  size  of 

rongly  bound  in  cloth,  $17  00  ;  also,  in  five  parts,  stout  wrappers,  at  $3  per  part. 

Anticipating  a  very  large  sale  for  this  work,  it  is  offered  at  the  very  low  price  of  THREBDOI,- 

fcARS  a  Part,  thus  placing  it  within  the  reach  of  all  who  are  interested  in  this  department  of 

practice.     Gentlemen  desiring  early  impressions  of  the  plates  would  do  well  to  order  it  without 

delay.     A  specimen  of  the  plates  and  text  sent  free-  by  mail,  on  receipt  of  25  cents. 

We  wish  for  once  that  onr  province  was  not  re-    to  its  end,  we  do  not  know  a  single  medical  work, 


strict  d  to  methods  of  treatment,  that  we  might  say 
some-hing  of  the  exquisite  colored  plates  In  this 
volume.  -London  Practitioner,  May,  1869.  . 

As  a  whole,  It  teachea  all  that  can  be  taught  by 
means  of  plates  and  print. — London  Lancet,  March 
IS,  1869. 

Superior  to  anything  of  the  kind  ever  before  issued 
on  this  continent. — Canada Med.  Journal,  March, '69 

The  practitioner  who  desires  to  understand  this 
branch  of  medicine  thoroughly  should  obtain  this, 
the  most  complete  and  best  work  ever  published.— 
Dominion  Med.  Journal,  May,  1869. 

This  ig  a  work  of^master  hands  on  both  sides.  M. 
Gollerier  is  scarcely  gecond  to,  we  think  we  may  truly 
say  ig  a  peer  ofthe  illustriousand  venerable  Ricord, 
while  in  this  country  we  do  not  hesitate  to  say  that 
Dr.  Bumstead,  as  an  authority,  is  without  a  rival 
Assuring  onr  readers  that  these  illustrations  tell  the 
whole  history  of  venereal  disease,  from  its  inception 


which  for  its  kind  is  more  necesnary  for  them  to 
have.—  California  3fed.  QanrMe,  March,  1869. 

The  most  splendidly  illustrated  work  In  the  lan- 
guage, and  in  our  opinion  far  more  useful  than  the 
French  original. — Am.  Jour.  Med.  Sciencet,  Jan.'6b. 

The  fifth  and  concluding  number  of  this  magnificent 
work  has  reached  us,  and  we  have  no  hesitation  in 
sayingthat  its  illustrations  surpassthose  of  previous 
cumbers. — Boat  Med.  and  Burg.  J!.,  Jan.  14  1869. 

Other  writers  besides  M.  Cullerier  have  given  us  a 
good  account  of  the  diseases  of  which  he  treats,  but 
no  one  hag  furnished  us  with  such  a  complete  series 
of  illustrations  of  the  venereal  diseases^  There  is, 
however,  an  additional  interest  and  value  possessed 
by  the  volnmebefore  UF;  forit  is  an  American  reprint 
and  translation  of  M.  Cullerier's  work,  with  inci- 
dental remarks  by  one  ofthe  most  eminent  Ameri- 
can lyphilographers,  Mr.  Bumstead. — Brit .andFoi . 
Medioo-Ohir.  Review,  July,  1869. 


' '  EE  (HENRY), 

•*        Prof,  of  Surgery  at  the  Rnyn  I  College  of  Snrgeon»  of  England,  etc. 

LECTURES  ON  SYPHILIS  AND  ON  SOME  FORMS  OF  LOCAL 

DISEASE  AFFECTING  PRINCIPALLY  THE  ORGANS  OF  GENERATION.    In  one 
handsome  octavo  volume:  cloth;  $2  25.     (Lately  Published.) 


The  work  is  valuable,  as  it  treats  quite  fully  of  sub- 
jects which  are  not  dwelt  upon  in  the  systematic  work? 
of  other  English  authors  of  the  present  day.  as  the  in- 
oculability  of  syphilitic  blood;  the  conditions  under 
which  the  secretions  of  primary  and  secondary  syphi- 
litic manifestations  may  be  inoculated  naturally  or 
artificially;  the  morbid  processes  produced  bs  such  Inoc- 


ulation; the  moflifirations  of  these  processes  in  patients 
previous'y  syphilitic:  primary  and  secondary  syphilitic 
diseases  ofthe  mucous  membranes  and  their  liability 
to  communicate  constitutional  syphilis,  etc.  The  book 
is  full  of  clinical  material  illustrating  these  topics, 
original  or  quoted. — Arc/lives  of  Dermatology,  April, 
1876. 


TJ1LL  (BERKELEY), 

-*--*•  Surgeon  to  the  Lock  Hoxpital,  London. 

ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  DISORDERS. 

one  handsome  octavo  volume  ;  cloth,  $3  25. 


In 


20         HENRY  C.  LEA'S  PUBLICATIONS — (Diseases  of  the  Skin,  (fee.). 
'pl3X  (TILBURY),  M.D.,F.R.C.P.,and  T.  C.  FOX,  B.A.,  M.K.C.S., 

Physician  to  the  Department  for  Skin  Diseases,  University  College  Houjntnl. 

EPITOME  OF  SKIN  DISEASES.    WITH  FORMULAE.     FOR  STU- 

DENTS  AND  PRACTITIONERS.    Second  edition,  thoroughly  revised  and  gre.'itly  enlarged.  In 
one  very  handsome  12ino.  volume  of  216  pages.     Cloth,  $1  38.     (Just  Ready.) 

PREFACE. 

In  preparing  this  edition  of  our  "EPITOME"  for  publication  in  the  United  States,  we  have 
increased  the  matter  to  about  three  times  its  original  amount.  The  kindly  appreciation  mani- 
fested for  the  work  by  the  American  profession  hns  stimulated  us  to  spare  no  pains  in  rendering 
it  more  worthy  of  their  approbation,  and  in  its  enlarged  form  we  believe  that  it  will  be  found  of 
enhanced  value.  About  two-thirds  of  the  work  is  newly  written,  and  we  may  direct  attention 
particularly  to  the  section  regarding  the  Pathology  of  the  Skin,  which  has  been  entirely  recast. 
and  now  contains  a  concise  account  of  all  the  important  changes  taking  place  in  the  dermal 
textures  in  disease.  The  clinical  descriptions  of  diseases  also  have  been  amplified  and  occasion- 
ally remodelled.  Lastly,  we  may  say  that  in  adding  material  to  the  book  we  have  selected  such 
as  bears  on  the  practical  side  of  Dermatology,  to  the  exclusion  of  that  which  is  as  yet  hypo- 
thetical or  merely  of  interest  to  the  curious  student. 

The  favorable  reception  accorded  to  the  work  on  both  sides  of  the  Atlantic  would  seem  to 
show  that  it  has  realized  the  object  with  which  it  was  prepared — to  afford  assistance  to  the  stu- 
dent in  his  early  study  of  dermatology,  and  to  serve  as  a  manual  for  ready  reference  by  the 
practitioner  in  his  daily  practice.  For  this  latter  purpose  it  has  been  specially  adapted,  by 
means  of  the  references  made  in  the  sections  on  treatment  to  the  formulae  at  the  end. 


WILSON  (  ERASM  us),  F.  R.  s. 

THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE  and  Dis- 

BASES  OF  THE-  SKIN.    In  one  very  handsome  royal  12ino.  volume.   $3  50. 


(J.MOORE),  M.D.,M.R.I.A. 
ATLAS  OF  CUTANEOUS  DISEASES.     In  one  beautiful  quarto 

volume,  with  exquisitely  colored  plates,  <tc.,  presenting  about  one  hundred  varieties  of 
disease.     Cloth,  $5  50. 

TJ1LLIER  (THOMAS),  M.D., 

Physician  to  the  Skin  Department  of  University  College  Hospital,  etc. 

HAND-BOOK  OF  SKIN  DISEASES,  for  Students  and  Practitioners. 

Second  Am.  Ed.     In  one  royal  12mo.  vol.  of  358  pp.    With  Illustration:.     Cloth,  $2  25. 


It  is  a  concise,  plain,  practical  treatise  <ju  the 
var.ous  diseases  of  the  skin  ;  just  such  a  work, 
indeed  as  was  much  needed,  both  by  medical  stu- 
dents ard  practitioners.  —  Chicago  Medical  Ex- 
aminer, Maj  1865. 


We  can  conscientiously  recommend  it  to  the  stu- 
dent ;  the  style  is  clear  and  pleasant  to  read,  the 
matter  is  good,  andthe  descriptions  of  disease,  with 
the  modes  of  treatment  recommended,  are  frequent- 
ly Illustrated  with  well-recorded  cases. — London 
Ifed.  Cimes  and  Gazette,  April  1,  1865. 

WEST  (CHARLES),  M.D., 

Physician  to  the  Hospital  for  Sick  Children,  London,  Sec. 

LECTURES  ON  THE  DISEASES  OF  INFANCY  AND   CHILE- 

HOOD.  Fifth  American  from  the  sixth  revised  and  enlarged  English  edition.     In  one  large 
and  handsome  octavo  volumeof  678  pages.    Cloth,  $4  50  ;  leather,  $5  50.  (Lately  Issued  ) 

The  continued  demand  for  this  work  on  both  sides  of  the  Atlantic,  and  its  translation  into 
German,  French,  Italian,  Danish,  Dutch,  and  Russian,  show  that  it  fills  satisfactorily  a  want 
extensively  felt  by  the  profession.  There  is  probably  no  man  living  who  can  speak  with  the 
authority  derived  from  a  more  extended  experience  thnn  Dr.  West,  and  his  work  now  presents 
the  results  of  nearly  2000  recorded  cases,  and  600  post-mortem  examinations  selected  from 
among  nearly  40,000  sases  which  have  passed  under  his  care.  In  the  preparation  of  the  pre- 
sent edition  he  has  omitted  much  that  appeared  of  minor  importance,  in  order  to  find  room  for 
the  introduction  of  additional  matter,  and  the  volume,  while  thoroughly  revised,  is  therefore 
not  increased  materially  in  size. 

or  all  the  English  writers  on  the  diseases  of  chil-  I  highest  living  authorities  in  the  difficult  department 
dran,  there  is  no  one  so  entirely  satisfactory  to  u§  |  of  medical  science  in  which  he    is   most  widely 
a*  Dr.  West.    For  years  we  have  held  his  opinion  I  known.-  Boston  Med.  and  Surg.  Journal. 
as  judicial,  and  have  regarded  him  as  one  of  the  I 

1DY  THE  SAME  AUTHOR.    (Lately  Issued.) 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 
HOOD; being  the  Lumleian  Lectures  delivered  at  the  Royal  College  of  Physicians  of 
London,  in  March,  1871.  In  one  volume  small  12mo.,  cloth,  $1  00. 

JfY  THE  SAVE  AUTHOR. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     Third  American, 

from  the  Third  London  edition.     In  one  neat  octavo  volume  of  about  550  pages,  clotL, 
$3  75;  leather,  $4  75. 


HENRY  C.  LEA'S  PUBLICATIONS — (Disease?  of  Children}.  21 

&MITH  (J.  LE  WIS),  M.D., 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Mtd.  College,  N  Y. 

A  COMPLETE  PRACTICAL  TREATISE  ON  THE  DISEASES  OF 

CHILDREN.    Fourth  Edition,  revised  and  enlarged.     In  one  handsome  octavo  volume 
of  about  750  pages,  with  illustrations.     Cloth,  $4  50  ;   leather,  $5  50.     (Roiv  Ready.) 
The  very  marked  favor  with  which  this  work  has  been  received  wherever  the  English  lan- 
guage is  spoken,  has  stimulated  the  author,  in  the  preparation  of  the  Fourth  Edition,  to  spare 
no  pains  in  the  endeavor  to  render  it  worthy  in  every  respect  of  a  continuance  of  professional 
confidence.,    Many  portions  of  the  volume  have  been  rewritten,  and  much  new  matter  intro- 
duced, but  by  an  earnest  effort  at  condensation,  the  size  of  the  work  has  not  been  materially 
increased. 

In  the  period  which  has  elapsed  since  the  third  '  It  is  scarcely  necessary  for  us  to  say  th«  work  be- 
edition  of  the  work,  so  extensive  have  been  the  ad-  fore  us  is  a  standard  work  upon  diseases  of  children, 
vauces  that  whole  chapters  required  to  be  rewritten,  and  that  no  work  has  a  higher  standing  than  it  upon 
and  hardly  a  page  could  pass  without  some  material  those  affections.  In  consequence  of  its  thorough  re- 
correction  or  addition.  This  labor  has  occupied  the  vision,  the  work  has  been  made  of  more  value  than 
writer  closely,  and  he  has  performed  it  cun*cien-  ever,  and  may  be  regarded  as  fully  abreast  of  the 
tionaly,  so  that  the  book  may  be  considered  a  faith-  times.  We  cordially  commend  it  to  students  and 
ful  portraiture  of  an  exceptionally  wide  clinical  physicians  There  is  no  better  work  in  the  langnage 
experience  in  infantile  diseases,  c  rrected  by  a  care-  on  diseases  of  children. — Cincinnati  Med.  Ntios, 
fol  study  of  the  recent  literature  of  the  subject. —  March,  1879. 
Med.  and  Surg.  Reporter,  April  5,  1879. 


riONDIE  (D.  FRANCIS),  M.D. 
'  A  PRACTICAL  TREATISE   ON   THE  DISEASES  OF  CHIL- 

dren.     Sixth  edition,  revised  and  augmented.    In  one  large  octavo  volume  of  nearly  800 
closely-printed  pages,  cloth,  $5  25  :  leather.  $6  25. 

gVITH (EUSTACE),  M.D., 

Physician  to  the  Northwest  London  Free  Dispensary  for  Siclt  Children. 

A  PRACTICAL  TREATISE  ON   THE  WASTING   DISEASES  OF 

INFANCY    AND   CHILDHOOD.    Second  American,  from  the  second  revised  and  en- 
larged English  edition.  In  one  handsome  octavo  volume,  cloth,  $2  50.  (Lately  Issued.) 

&  WAYNE  (JOSEPH  GRIFFITHS),  M.D., 

Physician- Accoucheur  to  the  British  General  Hospital.  Ac. 

OBSTETRIC  APHORISMS  FOR  THE  USE  OF  STUDENTS  COM- 
MENCING MIDWIFERY  PRACTICE  Second  American,  from  the  Fifth  and  Revised 
London  Edition  with  Additions  by  E.  R.  HUTCHINS,  M.D.  With  Illustrations.  In  one 
neat  12mo.  volume.  Cloth.  $1  25.  (Lately  Issued.) 

##*  See  p.  4  of  this  Catalogue  for  the  terms  on  which  this  work  is  offered  as  a  premium  to 
lubscribers  to  the  "  AMERICAN  JOURNAL  OF  THE  MEDICAL  SCIENCES." 


CHURCHILL  ON  THE  PUERPERAL  FEVER  AND 
OTHER  DISEASES  PECULIAR  TO  WOMEN.  1  vol. 


.  4.10,  cloth      %2  50 


MEIGS  ON  THE  NATURE,  SIGNS.   AND  TREAT- 
MENT OF  CHILDBED  FEVER.    1  vol.  8vo  ,  pp. 
365.  cloth      $2  00. 


DEwWyS  TREATISE  ONTHE  DISEASES  OF  FE- 1  ASHWELL's"pRACTICAL  TREATISE  ONTHE  DH- 
MALES.    With  illustrations.    Eleventh  Edition,  j      EASES  PECULIAR  TO  WOMEN.  Third  American, 


from  the  Third  and  revised  London  edition.  Ivo!. 
8vo.,  pp.  528,  cloth.    $3  50. 


MALES.    With  illustrations.    Eleventh  Edition,  j 
with  the  Author's  lastimprovementB  and  correc- 
tions.   In  one  octavo  volume  of  536  pages,  with 
plates,  cloth.    $3  00. 

TJODGE  (HUGH  L.),  M.D., 

Emeritus  Professor  of  Obstetrics,  Ac.,  in  the  University  of  Pennsylvania. 

ON  DISEASES  PECULIAR  TO  WOMEN  ; including  Displacements 

of  the  Uterus.     With  original  illustrations.    Second  edition,  revised  and  enlarged.     In 
one  beautifully  printed  octavo  volume  of  531  pages,  cloth,  $4  50. 


Professor  Hodge's  work  Is  truly  an  original  one 
from  beginning  to  and,  consequently  no  one  can  pe- 
tase  its  pages  without  learning  something  new.  At  a 


contribution  tothe  study  ofwomen'Bdifeases.itisrf 
great  value,  and  is  abundantly  able  to  stand  on  its 
own  merits  —  N.  Y.  Mtdical  Record,  Sept.  15,  166*. 


SIHURCHILL  (FLEETWOOD),  M.D.,  M.R.I.A. 

V   ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.    A  new 

American  from  the  fourth  revised  and  enlarged  London  edition.  With  notes  and  add,t,or  a 
by  D   FRANCIS  CONDIE,  M.D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  ( 
dren  "  Ac.  With  one  hundred  and  ninety  four  illustrations.  In  one  very  handsome  octa 
volume  of  nearly  700  large  pages.     Cloth,  $4  00  ;  leather,  $5  00. 

EXPOSITION   OF    THE   SIGNS  i  RIGBY'B  SYSTEM  OF  MIDWIFERY.     With  notes 


In  1  vol.  8vo.,  of  nearly  600  pp.,  cloth,  $3  75. 


HENRY  C.  LEA'S  PUBLICATIONS— (Diseases  of  Women). 


fTROMAS  (T.GAILLARD),M.D., 

i-  Profetsor  of  Obstetrics,  *c. ,  in  the  College  o/  Physicians  and  Surgeons,  N.  T.,Ac. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  WOMEN.  Fourth 

edition,  enlarged  and  thoroughly  revised.  In  one  large  and  handsome  octavo  volume  of 
800  pages,  with  191  illustrations.     Cloth,  $5  00;  leather,  $6  00.     (Just  Issued.) 
The  author  has  taken  advantage  of  the  opportunity  afforded  by  the  call  for  another  edition  of 
this  work  to  render  it  worthy  a  continuance  of  the  very  remarkable  favor  with  which  it  has  been 
received.  Every  portion  has  been  subjected  to  a  conscientious  revision,  and  no  labor  has  been 
spared  to  make  it  a  complete  treatise  on  the  most  advanced  condition  of  its  important  subject. 
A  work  which   has  reached   a  fourth   edition,  and  j  tsclasMcal  without  beingpedantic.full  in  the  details 
that,  too.  in  the  short  space  of  five  years,  has  achieved    of   anatomy    and    pathology,    without  ponderous 
a  reputation  which  places  it  almost  beyond  the  reach  I  translation  of  pages  of  German  literature,  describe 
of  criticism,  and  the  favorable  opinions  which  we  have  j  distinctly  the  details  and  difficulties  of  each  opera- 
a'roady  expressed  of  the  former  editions  seem  to  re-1  tiou,  without  wearying  and  useless  minutiae,  and  is 
quire  that  we  should  do  little  more  than  announce  ,  in  all  respects  a  work  worthy  of  confidence,  justify- 
this  new  issue.    We  cannot  refrain  from  saying  that, !  ing  the  high  regard  In  which  its  distinguished  an- 
as a  practical  work,  this  is  second  to  none  in  the  Eng-  j  thor  is  held  by  the  profession.—  Am.  Supplement, 


Hsh,  or,  indeed,  in  any  other  language.  The  arrange 
ment  of  the  contents,  the  admirably  clear  manner  in 
which  the  subject  of  the  differential  diagnosis  of 
Several  of  the  diseases  is  handled,  leave  nothing  to  be 
desired  by  the  practitioner  who  wants  a  thoroughly 
clinical  work,  one  to  which  he  can  re*er  in  difficult 
eases  of  doubtful  diagnosis  with  the  certainty  of  gain- 
ing light  and  instruction.  Dr.  Thomas  is  a  man  with  a 
very  clear  head  and  decided  views,  and  there  seems  to 
be  nothing  which  he  so  much  dislikes  as  hazy  notions 
of  diagnosis  and  blind  routine  and  unreasonable  thera- 


Obstet.  Journ.,  Oct.  1874. 

Professor  Thomas  fairly  took  the  Profession  of  the 
United  States  by  storm  when  his  book  first  made  its 
appearance  early  in  1S68.  Its  reception  was  simply 
enthusiastic,  notwithstanding  a  few  adverse  criti- 
cisms from  our  transatlantic  brethren,  the  first  large 
edition  was  rapidly  exhausted,  and  in  six  months  a 
second  one  was  isaned.and  in  two  yearsathird  one 
was  announced  and  published,  and  we  are  now  pro- 
mised the  fourth.  The  popularity  of  this  work  was 


f  diagnosis  anil  bind  routine  ana  unreasonable  tnera-    -    - —  *"-  .  .""  .      ,~Atn 

eutics.    The  student  who  will  thoroughly  study  this    »»*  ephemeral,  and  itssuccess ^unprecedented 
x*  and  test  its  principles  by  clinical  observation,  will    the  annaUof  American  medical  literature.  S 
rtainly  not  be  guilty  of  these  faults.-iondon  Za«c«<, !  ls  a  loB?  P9rlod  in  medical  scientific  research    but 
eh  n   is-1!  1  Thomas's  work  on  "  Diseases  of  Women"  is  still  the 

leading  native  production  of  the  United  States.  The 


leaaiug  ua' i ve  pruu uuuuu  ui  IUB  uuneu  omn3o.    *  »«w 
Reluctantly  we  are  obliged  to  close  this  unsatis-    orderi  the  matter,  the  absence  of  theoretical  dispni  a- 


factory  notice  of  so  excellent  a  work,  and  in  cone lu 


tiveness,  the  fairness  of  statement,  and  the  elegarc« 


RARNES  (ROBERT),  M.D.,  F.R.O.P., 

•*-*  Obstetric  Physician  to  St.  Thomas's  Hotpital,  itc.   • 

A  CLINICAL  EXPOSITION  OF  THE  MEDICAL  AND  SURGI- 
CAL DISEASES  OF  WOMEN.  Second  American,  from  the  Second  Enlarged  and  Revised 
English  Edition.  Inon«  handsome  octavo  volume,  of  784  pages,  with  181  illustrations. 
Cloth,  $4  50;  leather,  $5  50.  (Just  Ready.) 

The  call  for  a  new  edition  of  Dr.  Barnes's  work  on  the  Diseases  of  Females  has  encouraged 
the  author  to  make  it  even  more  worthy  of  the  favor  of  the  profession  than  before.  By  a  rear- 
rangement and  direful  pruning  space  has  been  found  for  a  new  chapter  on  the  Gynaecological 
Relations  of  the  Bladder  and  Bowel  Disorders,  without  increasing  the  size  of  the  book,  while 
many  new  illustrations  have  been  introduced  where  experience  has  shown  them  to  be  needed.  It 
is  therefore  hoped  that  the  volume  will  be  found  to  reflect  thoroughly  and  accurately  the  present 
condition  of  gynaecological  science. 

Dr  Barnes  stands  at  the  head  of  his  profession  in  th«  work  is  a  valuable  one,  and  should  be  largely 
the  old  country,  and  it  requires  but  scant  scrutiny  consulted  by  the  profession. — Am.  8->pp  Obstetrical 


of  his  hook  to  show  that  it  has  been  sketched  by  a 
master.  It  is  plain,  practical  common  sense  ;  shows 
very  deep  research  without  being  pedantic ;  is  emi- 


Journ.  Gt.  Britain  and  Ireland,  Oct.  1S78. 

No  other  gynaecological  work  holds  a  higher  posi- 
tion, having   become   an   authority  everywhere  in 


nently  calculated  to  inspire  enthusiasm  without  in-  dlsease.s  of  women.  The  work  has  been  bronght 
culcating  rashness;  points  out  the  dangers  to  be  j  fully  abreast  of  present  knowledge.  Every  praeti- 
a  voided  as  well  as  the  success  to  be  achieved  in  the  !  tion'er  of  medlollje  8nould  lliire  it  upon  the  shelves 
various  operations  connected  with  this  branch  of  |  of  his  lib rary  and  the  gtudent  will  find  it  a. superior 
medicine;  and  will  do  much  to  smooth  the  rugged  I  t«t-book.-«n<*n»att  Med.  News,  Oct.  1S7S. 
path  of  the  young  gynaecologist  and  relieve  the  per- 


plexity of  the   man   of  mature  year*.  —  Canadian 
Journ.  of  Med.  Science,  Nov.  1S78. 


This  second  revised  edition,  of  course,  deserves  all 
the  commendation  given  to  its  predecessor,  with  the 
additional  one  that  it  appears  to  inclnde  all  or  nearly 
We  pity  the  doctor  who,  having  any  consider- i  all  the  additions  to  our  knowledge  of  its  subject  that 
able  practice  in  diseases  of  women,  has  no  copy  of  1  have  been  made  *ince  the  appearance  of  the  first  edi- 
•'  Barnes"  for  daily  consultation  and  instruction.  It  !  tion  The  American  references  are,  for  an  English 
is  at  once  a  book  of  great  learning,  research,  and  j  work,  especially  full  and  appreciative,  and  we  can 
Individual  experience,  and  at  the  same  time  eml-  cordially  recommend  the  volume  to  American  rpiid- 
nently  practical.  That  it  has  been  appreciated  by  ]  ers — Joitrn.  of  Nervous  and  Mental  Disiase,  Oct. 


the  profession,  both  in  Great  Britain  and  in  this 
country,  is  shown  by  the  second  edition  following 
so  soon  upon  the  first. — Am.  Practitioner,  Nov. 
1873. 

Dr  Barnes'*  work  Is  one  of  a  practical  character, 
largely  illustrated  from  cases  in  his  own  experience, 


1878. 

This  second  edition  of  Dr.  Barnes's  great  work 
comes  to  us  containing  many  additions  and  improve- 
ments which  bring  it  up  to  date  in  every  feature. 
The  excellences  of  the  work  are  too  well  known  to 
require  enumeration,  and  we  hazard  'he  prophecy 


bat  by  no  means  confined  to  such,  as  will  be  learned  i  that  they  wi'l  for  many  years  maintain  its  high  po- 
from  the  fact  that  he  quotes  from  no  less  than  62S  siti.m  as  a  standard  text-book  and  guide  book  for 
medical  authors  in  numerous  countries.  Coming  •  students  and  practitioners.  —  N.  0.  Mud.  Journ., 
from  buch  an  author,  it  is  not  necessary  to  say  that  ;  Oct.  1878. 


HENRY  C.  LEA'S  PUBLICATIONS-^  Diseases  of  Women).  23 

f]MMET  (THOMAS  ADDIS).  M.D. 

Snrge.on  to  the  Woman's  Hospital,  N>w  York,  el'. 

THE  PRINCIPLES  AND  PRACTICE  OF  GYNAECOLOGY,  for  the 

use  of  Students  and  Practitioners  of  Medicine.     In  one  large  and  very  handsome  octavo 
volume  of  806  pages,  with  130  illustrations.     Cl  tb,  $5;  leather,  $6.      (Just  Ready.) 
Dr   Emmet  is  so  widely  known  as  among  the  most  eminent  of  those  who  have  made  gvnee- 
oology  a  peculiarly  American  science  that  the  profession  cannot  fail  co  welcome  a  work  in  which 
he  has  condensed  the  results  of  his  long  and  extensive  experience.     He  has  sought  to  consider 
the  whole  subject  of  the  diseases  peculiar  to  females  in  a  manner  which  will  adapt  the  volume, 
not  only  to  the  wants  of  the  student  as  a  text-book,  but  to  those  of  the  practitioner  as  an  aid  in 
he  emergencies  of  daily  practice.     A  special  feature  of  the  work  will  be  f-und  in  the  numerous 
condensed  tables,  which  convey  at  a  glance,  and  within  the  narrowest  compass,  the  conclusions 
to  be  drawn  from  the   many  thousand  cases  which   have  passed  under  the  care  of  the  author. 
AVith  trifling  exceptions,  the  illustrations  are  all  original,  and  the  volume  will  be  found  in  every 
point  of  typographical  execution  worthy  of  the  distinguished  position  which  is  confidently  anti- 
cipated for  it. 


(JHADWICK  (JAMES  R.),  A.M.,  M.D. 

A  MANUAL  OF  THE   DISEASES  PECULIAR  TO  WOMEN.    In  one 

neat  volume,  royal  12mo  ,  with  illustrations.     (Preparing,) 

America  has  contributed  so  largely  to  the  advances  which  have  made  the  treatment  of  Dis- 
eases of  Women  a  distinctive  department  of  medical  science,  that  the  student  will  naturally 
turn  to  American  Books  for  the  latest  and  most  trustworthy  instruction  on  the  subject  in  its 
most  modern  aspect.  Yet  there  has  thus  far  been  no  attempt  in  this  country  to  produce  a  handy 
manual,  presenting  in  a  condensed  and  convenient  form  the  information  requisite  for  the  learner 
or  for  the  general  practitioner.  This  want  it  h.-is  been  the  effort  of  Dr.  Chadwick  to  supply,  and 
the  special  attention  which  he  has  devoted  to  the  subject  is  a  guarantee  of  the  value  of  his  labors. 
A  distinguishing  feature  of  the  work  will  be  a  number  of  diagrammatic  illustrations,  facilitating 
greatly  the  comprehension  of  the  text. 

TUJNCKEL  (F.), 

Professor  and  Director  of  the  Gynecological  Clinic  in  the  University  of  Rostock. 

A  COMPLETE  TREATISE  ON  THE  PATHOLOGY  AND  TREAT- 
MENT OF  CHILDBED,  for  Students  and  Practitioners.  Translated,  with  the  consent 
of  the  author,  from  the  Second  German  Edition,  by  JAMES  READ  CHADWICK,  M.D.  In 
one  octavo  volume.  Cloth,  $4.00.  (Lately  Issued.) 


This  work  wa<  written,  as  the  author  tells  us  in 
preface,  to  supp'y  a  want  ari«in^  from  the  very  brief 


on  Obstetrics,  in  which  respect  it  seems  the  profession 
in  his  country  is  not  different  from  our»,  and  to  fill  a 
blank  left  between  the  treatises  upon  the  subject  al- 


ready in  the  field,  and  the  present  standpoint  of  sci- 
ence.   Tht   work   has  reached  a  second  edition,  and 


ution  given  to   puerperal  diseases  by  writers    bears  evidence  throughout  of  careful  study  and  prac 


tical  experience.  As  its  title  implies.it  is  a  manual 
rather  than  a  treatise. — American  Journal  o/JUfd.  Sci- 
ences, April,  1871. 


fFHE  OBSTETRICAL  JOURNAL.     (Free  of  postage  for  1879.) 

THE  OBSTETRICAL  JOURNAL  of  Great  Britain  and  Ireland; 

Including  MIDWIFERY,  and  the  DISEASESOF  WOMEN  AND  INFANTS.  With  an  American 
Supplement,  edited  by  J.  V.  INGHAM,  M.D.  A  monthly -of  about  9fi  octavo  pages, 
very  handsomely  printed.  Subscription,  Five  Dollars  per  annum.  Single  Numbers,  50 
cents  each. 

Commencing  with  April,  1873,  the  Obstetrical  Journal  consists  of  Original  Papertby  Brit- 
ish and  Foreign  Contributors;  Transactions  of  the  Obstetrical  Societies  in  England  and 
abroad.  Reports  of  Hospital  Practice;  Reviews  and  Bibliographical  Notices;  Articles  and 
Notes,  Editorial,  Historical,  Forensic,  and  Miscellaneous;  Selections  from  Journals;  Cor 
respondence,  Ac  Collecting  together  the  vast  amount  of  material  daily  accumulating  in  this 
important  and  rapidly  improving  department  of  medical  science,  the  value  of  the  infor- 
mation which  it  pre3ents  to  the  subscriber  may  be  estimated  from  the  character  of  the  gen- 
tlemen who  have  already  promised  their  support,  including  such  names  as  those  of  Drs.  AT- 
THILL,  AVELING,  ROBERT  BARNES,  J.  HENRY  BENNET,  NATHAN  BOZEMAN,  THOMAS  CHAMBERS, 
FLBBTWOOD  CHURCHILL,  CHARLES  CLAY,  JOHN  CLAY,  MATTHEWS  DUNCAN,  ARTHUR  FARRE, 
ROBERT  GREENHALGH,  GRAILY  HEWITT,  BRAXTON  HICKS,  ALFRED  MEADOWS,  W.  LKISH- 
MAN,  ALEX.  SIMPSON,  HEYWOOD  SMITH,  TYLER  SMITH,  EDWARD  J.  TILT,  LAWSON  TAIT, 
SPENCER  WELLS,  Ac.  Ac.  ;  in  short,  the  representative  men  of  British  Obstetrics  and  Gynse- 
cology. 

In  order  to  render  the  OBSTETRICAL  JOURNAL  fully  adequate  to  the  wants  of  the  Ameri- 
can profession,  each  number  contains  a  Supplement  devoted  to  the  advances  made  in  Obstet- 
rics and  Gynaecology  on  this  side  of  the  Atlantic.  This  portion  of  the  Journal  is  under 
the  editorial  charge  of  Dr  J.  V.  INGHAM;  to  whom  editorial  communications,  exchanges, 
books  for  review,  Ac.,  may  be  addressed,  to  the  care  of  the  publisher. 

%*  Complete  sets  from  the  beginning  can  no  longer  be  furnished,  but  subscriptions  can 
oom-uence  wuh  January,  1879,  or  Vol  VII.,  No  1,  April,  1879. 


24 


HENRY  C.  LEA'S  PUBIICATIONS — (Midwifery}. 


pLAYFAIR  (  W.  S.},  M.D.,  F.R.C.P., 

Professor  of  Obstetric  Medicine  in  King's  College, etc.  etc. 

A  TREATISE  ON  TFIE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 

Second  American,  from  the  Second  and  Revised  English  Edition.  Edited,  with  Addi- 
tions, by  ROBERT  P.  HARRIS,  M.D.  In  one  handsome  octavo  volume  of  639  pages,  with 
182  illustrations.  Cloth,  $4  00;  Leather,  $5.00.  (Just  Ready  ) 

In  reprinting  this  work  from  the  second  London  edition,  the  position  which  it  has  assumed 
in  this  country  ns  an  authoritative  test-book  seemed  to  call  for  such  additions  as  would  render 
it  more  completely  suited  to  the  wants  of  the  American  student.  A  careful  scrutiny  on  the  part 
of  the  editor  has  shown  that  but  little  was  required  for  this  purpose  ;  the  work,  though  condensed, 
being  very  complete  and  accurate.  With  the  exception  of  numerous  short  foot-notes,  therefore, 
his  additions  have  been  confined  to  points  in  which  the  experience  and  practice  of  American 
obstetricians  differ  from  those  of  England,  and  to  one  or  two  matters  of  recent  interest.  These 
ar§  chiefly  the  Csesarean  Section  ;  the  varieties  of  forceps,  and  their  use  in  the  dorsal  decubitus; 
dystocia  from  tetanoid  uterine  constriction;  and  the  intra-venous  injection  of  milk,  as  a  substi- 
tute for  the  transfusion  of  blood. 


The  position  which  this  work  has  so  qirckly  taken 
In  thia  country  as  an  authoritative  text-book  rentiers 
any  extended  consideration  of  its  plan  and  scope 
unnecessary.  Its  merits,  which  are  many,  have  al- 
ready found  their  way  to  the  appreciation  of  students 
and  practitioners  alike  in  the  length  and  breadth  of 
the  land. — Am.  Supp.  Obatet.  Journ.  of  Qt.  Britain 
and  Ireland,  Oct.  1878. 

This  excellent  text-book  has  been  submitted  to  a 
thorough  and  careful  revision,  and  will  be  found 
fully  np  to  the  times  in  every  department.  The 
cotes  by  the  American  editor  enhance  the  value  of 
the  work  for  the  American  student.  Those  on  the 
use  of  forceps  are  particnlirly  good,  and  constitute 
by  themselves  a  valuable  chapter. — N.  T.  Med. 
Journ.,  Nov.  1878. 

The  best  work  on  the  subject  ever  published  in  the 
English  language.  It  is  written  in  a  clear,  pleasant 
style,  without  that  verbosity  which  characterizes 
some  modern  and  highly  pretentious  works.  The  au- 
thor is  quite  up  with  the  times,  both  in  practice  and 


theory.  It  is  the  best  text-book  we  have  for  students, 
and  sufficiently  full  of  detail  to  supply  all  the  wants 
of  the  practitioner.  We  would  gladly  see  it  in  the 
hands  of  all  who  practise  midwifery.  —  Canadian 
Journ.  of  Med.  Soi.,  Nov.  1878. 

Probably  this  is  the  very  best  and  most  useful 
manual  of  midwifery  now  available  to  the  profes- 
sion. Itis  written  in  lucid,  scholarly  English,  which 
some  of  our  ois-Atlantic  writers  would  do  well  to 
imitate.  There  has  been  no  attempt  to  swell  the 
magnitude  of  the  work  by  fine  writing,  or  by  lengthy- 
discussions  ofobtcure  points  of  which  no  trustworthy 
solution  has  yet  been  reached  ;  on  the  contrary,  the 
tendency  is  throughout  obviously  towards  simplic- 
ity. The  chapter  upon  the  Mechanism  of  Labor 
(which  ought  to  be  the  crowning  chapter  in  a  trea- 
tise on  obstetrics)  is  remarkably  clear  and  good,  and 
is  divested  of  those  features  which  in  almost  every 
other  work  we  know  lets  only  darkness  instead  of 
light  in  upon  the  subject.  —  -V.  C.  Med.  Journ.,  Oct. 
1878. 


H 


'ODOE  (HUGH  L.),  M.D., 

Emeritus  Professor  of  Midwifery,  &c.,  in  the  University  of  Pennsylvania,  Ac. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS.     Illns- 

trated  with  large  lithographic  plates  containing  one  hundred  and  fifty-nine  figures  from 
original  photographs,  and  with  numerous  wood-cuts.  In  one  large  and  beautifully  printed 
quarto  volume  of  550  double-columned  pages,  strongly  bound  in  cloth,  $14. 

The  work  of  Dr.  Hodge  is  something   more  than  i  subject  it  is  decidedly  the  best.—  Edinb.  Med.  Jour., 
a  simple  presentation  of  his  particular  views  in  the  ••  Dec.  1864. 
department  of  Obstetrics;    it  is   something  more 


We    have   read    Dr.    Hodge's    book   with   great 


— Am.  Mf.d.  Times,  Sept.  3,  1864 


arrived,  point,  we  think,  conclusively  to  the  fact 


Ills  very  large,  profusely  and  elegantly  illustrat-  that,  in  Britain  at  least,  the  doctrines  of  Naegele 
ed,  and  is  fitted  to  take  its  place  near  the  works  of  have  been  too  blindly  received. — Glasgow  Med. 
great  obstetricians.  Of  the  American  works  on  the  i  Journal,  Oct.  1864. 

**#  Specimens  of  the  plates  and  letter-press  will  be  forwarded  to  any  address,  free  by  mail, 
on  receipt  of  six  cents  in  postage  stamps. 


WANNER  (THOMAS  H.),  M.D. 
'    ON  THE  SIGNS  AND  DISEASES  OF  PREGNANCY.    First  American 

from  the  Second  and  Enlarged  English  Edition.     With  four  colored  plates  and  illustra- 
tions on  wood.    In  one  handsome  octavo  volume  of  about  500  pages,  cloth,  $4  25. 


f>A MSB 0 TEA M  ( FRA NCIS  H.},  M.D. 

THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDI- 
CINE AND  SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged 
edition,  thoroughly  revised  by  the  author.  With  additions  by  W.  V.  KEATING,  M.  D., 
Professor  of  Obstetrics,  <fec.,  in  the  Jefferson  Medical  College,  Philadelphia.  In  one  Lirgre 
and  handsome  imperial  octavo  volume  of  650  pages,  strongly  bound  in  leather,  with  raised 
bands  ;  with  sixty-four  beautiful  plates,  and  numerous  wood-cuts  in  the  text,  containing  in 
all  nearly  200  large  and  beautiful  figures.  $7  00. 


HENRY  C.  LEA'S  PUBLICATIONS — (Midwifery,  Surgery}. 


25 


^EISHMAN  ( WILLIAM],  H.D., 

Regius  Professor  of  Midwifery  in  the  University  of  Glasgow,  Ac. 

A  SYSTEM  OF  MIDWIFERY,  INCLUDING  THE  DISEASES  OF 

PREGNANCY  AND  THE  PUERPERAL  STATE.  Second  American,  from  the  Second 
and  Revised  English  Edition,  with  additions  by  JOHN  S.  PARRY,  M.D.,  Obstetrician  to  the 
Philadelphia  Hospital,  <tc.  In  one  large  and  very  handsome  octavo  volume  of  over  700 
pages,  with  about  two  hundred  illustrations  :  cloth,  $5  ;  leather,  $6.  (Just  Issued.) 


That  this  book  is  recommended  as  a  text-book  by 
many  of  the  leading  scholars  of  medicine  in  tbis 
country,  is  sufficient  evidence  of  the  favor  in  which 
it  is  held.  In  a  word,  we  know  of  no  better  book  in 
our  language,  both  for  the  student  and  practitioner. 
The  value  of  the  book  is  enhanced  by  this  second 
edition,  which  contains  many  notes  by  our  late  Dr. 
Parry. — Chicago  Med.  Journ.  and  Examiner,  March. 
1877. 

But  the  most  valuable  additions  to  the  volume  are 
those  made  by  the  American  editor.  One  of  the  best  tests 
of  a  man's  ability  is  for  him  to  take  a  standard  work  in 
our  profession,  like  this  of  Dr.  Leishman,  and  materially 
improve  it.  Many  a  one,  with  more  ambition  than  wis- 
dom, has  attempted  it  with  other  books  and  failed.  But 
Dr.  Parry  has  succeeded  most  admirably.  We  know  no 
obstetrical  work  that  has  anything  better  on  the  use  of 
the  forceps  than  that  which  Dr.  Parry  has  given  in  this, 
and  no  work  that  has  the  rational  and  intelligent  views 
upon  lactation  with  which  he  has  enriched  this.  Having 
used  "  Lcishman"  for  two  years  as  a  text-book  for  stu- 
dents,wecancordiallycommendit.andarequite  satisfied 
to  continue  such  use  now. — Am.  Practitioner,  Mar.  1876. 

Tbis  new  edition  decidedly  confirms  the  opinion  which 
we  expressed  of  the  first  edition  of  tbe  work,  in  the  May, 
1S74,  number  of  this  Journal,  that  this  is  "thebest 
modern  work  on  the  subject  in  the  English  language." 
The  excellent  practical  notes  contributed  by  Dr.  Parry 
refer  pri ncipal ly  to  the  use  of  the  forceps,  lactation ,  and 
the  puerperal  diseases,  and  are  intended  to  increase  the 
usefulness  of  the  work  in  this  country.  An  entirely  new 
chapter  on  diphtheria  of  puerperal  wounds  has  been 


added  (Dr.  P.  has  had  unusual  experience  in  this  form 
of  puerperal  fever),  and  also  a  number  of  illustrations 
of  the  principal  obstetrical  instruments  in  usein  Ame- 
rica. We  have  no  hesitation  in  saying  thatthe  work,  in 
its  present  shape,  is  a  great  improvement  on  its  prede- 
cessor, and  in  recommending  it  as  tbe  one  obstetrical 
text- book  which  we  should  advise  every  English  f  peak- 
ing practitioner  and  student  to  buy. — American  Jour- 
nal of  Obstetrics,  Feb.  1876. 

Perhaps  the  most  useful  one  the  student  can  procure. 
Some  important  additions  have  been  made  by  the  editor, 
in  order  to  adapt  the  work  to  the  profession  in  this  coun- 
try, and  some  new  illustrations  have  been  introduced, 
to  represent  the  obstetrical  instruments  generally  em- 
ployed in  American  practice.  In  its  present  form,  it  is 
an  exceedingly  valuable  book  for  both  the  student  and 
practitioner. — JV>u»  York  JUed.  Journal,  Jan.  1876. 

Since  the  publication  of  Tyler  Smith's  lectures  on 
midwifery,  no  text  book  which  was  in  reality  the 
exponent  of  British  practice  has  appeared  in  the 
English  language  until  Dr.  Lei&hman  supplied  the 
want  by  his  system  of  midwifery,  which  was  pub- 
lished about  three  years  ago.  The  chief  feature  in 
this  work  is  the  exactness  in  description  of  the  me- 
chanism of  labor  ;  it  exhibits  most  accurate  obser- 
vation, and  is  a  perfect  analysis  of  the  subject,  it  is 
clear,  precise  and  masterly.  The  work  is  in  every 
way  a  valuable  addition  to  the  works  already  be- 
fore the  profession  on  the  science  and  practice  of 
obstetrics,  and  will,  we  doubt  not,  be  the  favorite 
text-book  used  in  our  schools. — Canada  Med.and 
Surg.  Journal,  Nov.  1S76. 


P 


ARRY  (JOHN  S.),  M.D., 

Obstetrician  to  th«  Philadelphia  Hospital,  Viee-Prest.  of  the  Obstet.  Society  of  Philadelphia. 

EXTRA-UTERINE    PREGNANCY:    ITS  CLINICAL  HISTORY, 

DIAGNOSIS,    PROGNOSIS,  AND   TREATMENT.     In  one  handsome  octavo  volume. 
Cloth,  $2  60.     (Lately  Issued.) 

This  work. being  as  near  as  possible  a  collection  of  the 


In  this  work  Dr.  Parry  has  added  a  most  valuable 
contribution  to  obstetric  literature,  and  one  which 
meets  a  want  long  felt  by  those  of  the  profession  who 
have  ever  been  called  upon  to  deal  with  this  class  of 
cases.— Boston  Med.  and  Surg.  Journ..  March  9, 1876. 


experiences  of  many  persons,  will  afford  a  most  useful 
guide,  beth  in  diagnosis  and  treatment,  for  this  most 
interesting  and  fatal  malady.  We  think  it  should  be  in 
the  hands  of  all  physicians  practising  midwifery.— Cin- 
cinnati Clinic,  Feb.  5, 1876. 


(LEWIS  A.},  A.M.,  M.D., 

Surgeon  to  the  Presbyterian  Hospital. 

A  MANUAL  OF  OPERATIVE  SURGERY.     In  one  very  handsome 

royal  12mo.  volume  of  about  500  pages,  with  332  illustrations  ;  cloth,  $2  50.  (Now  Ready.) 
The  work  before  us  is  a  well  printed,  profusely  ,  performing  them.     The  work  is  handsomely  illus- 
illnstrated  manual  of  over  four  hundred  and  seventy  !  trated,  and  the  descriptions  are  clear  and  well  drawn. 
m^-    : i,..  .  „„...,...,]  ^t  n,o  TT.,,VV    nriii     it    ia   a  flprpr  and    nsafnl  volume:   every  student 


pages.  The  novice,  by  a  perusal  of  the  work,  will 
gain  a  good  idea  of  the  general  domain  of  operative 
surgery,  while  the  practical  surgeon  has  presented 
to  him  within  a  very  concise  and  intelligible  form 
the  latest  and  most  approved  selections  of  operative 
procedure.  The  precision  and  conciseness  with  which 
the  different  operations  are  described  enable  the 
author  to  compress  an  immense  amount  of  practical 
Information  in  a  very  small  compass. — N.  Y.  Medical 
Record,  Aug.  3,  1878. 
This  volume  is  devoted  entirely  to  operative  snr- 


s  voume    s    evoe     en  , 

gery,  and  is  intended  to  familiarize  the  student  with  •  -Cincinnati  Lancet  an 
the  details  of  operations  and  the  different  modes  of  I 


It  is  a  clever  and  useful  volume ;  every  student 
should  possess  one.  The  preparation  of  this  work 
does  away  with  the  necessity  of  pondering  over 
larger  works  on  surgery  for  descriptions  of  opera- 
tions, as  it  presents  in  a  nut-shell  just  what  is  wanted 
by  the  surgeon  without  an  elaborate  search  to  find 
it. — Md.  Med  Journal,  Aug.  1878. 

The  author's  conciseness  and  the  repleteness  of 
the  work  with  valuable  illustrations  entitle  it  to  be 
classed  with  the  text-books  for  students  of  operative 
snreery,  and  as  one  of  reference  to  the  practitioner. 

:?      •_  i   f*t-..-t-     T..I..  OT    ic'rc 


,  ,,    V? 
c,  July  27, 


SKET'S  OPERATIVE  SURGERY.  In  1  rol.  8vo. 
el.,  of  650  pages';  withabout  100wood-«uts.  $3  26 

COOPER'S  LECTURES  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  SUROERY.  In  1  vol.  8vo.  cl'h,  750  p.  $2. 

GIBSON'S  INSTITUTES  AND  PRACTICE  OF  SUR- 
OBKT.  Eighth  edit'n,  improved  and  altered.  With 
thirty-four  plates.  In  two  handsome  octavo  vol- 
umes, about  1000  pp..  leather,  raised  bandp.  *6  50. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY. 
By  WILLIAM  PiRKiB,F.R.S.E.,Profe*'rof  Surgery 
u  the  University  of  Aberdeen.  Edited  by  Jons 


NEILL,  M.D.,  Professor  of  Surgery  in  the  Petna. 
Medical  College,  Surg'n  to  the  Pennsylvania  Hos- 
pital, &c.  In  one  very  handsome  octavo  vol.  of 
780  pages,  with  316  illustrations,  cloth,  $3  75. 

MILLER'S  PRINCIPLESOF  SURGERY.  Fourth  Ame- 
rican, from  the  Third  Edinburgh  Edition.  In  cue 
large  8vo.  vol.  of  700  pages,  with  340  illustrations, 
cloth,  $375. 

MILLER'S  PRACTICE  OF  SURGERY.  Fourth  Ame- 
rican, from  the  last  Edinburgh  Kdition  Revised  by 
the  American  editor.  In  onelargeSvo.  vol. of  nearly 
700  pages,  with  364  illustrations:  cloth, $3  75. 


26 


HE.NTRY  C.  LEA'S  PUBLICATIONS — (Surgery 


S7ROSS  (SAMUEL  D.),  M.D., 

Prof ef/ior  of  Surgery  in  the  Jf.ffi.rson  Medical  College  of  Philadelphia. 

SYSTEM  OF    SURGERY:   Pathological,  Diagnostic,  Therapeutic, 

and  Operative.    Illustrated  by  upwards  of  Fourteen  Hundred  Engravings.   Fifth  editioi. 
carefully  revised,  and  improved.  In  two  large  and  beautifully  printed  imperial  octavo  vol- 
umes of  about  2300  pp.,  strongly  bound  in  leather,  with  raised  bands,  $15.    (Juft  Issued.} 
The  continued  favor,  shown  by  the  exhaustion  of  successive  large  editions  of  this  great  work, 
proves  that  it  has  successfully  supplied  a  want  felt  by  American  practitioners  and  students.     In 
tht  present  revision  no  pains  have  been  spared  by  the  author  to  bring  it  in  every  respect  fully 
up  tc  the  day.     To  effect  this  a  large  part  of  the  work  has  been  rewritten,  and  the  whole  en- 
arged  bj  nearly  one-fourth,  notwithstanding  which  the  price  has  been  kept  at  its  former  very 
moderate  rate.     By  the  use  of  a  close,  though  very  legible  type,  an  unusually  large  amount  ol 
matter  is  Jondensed  in  its  pages,  the  two  volumes  containing  as  much  as  four  or  five  ordinary 
octavos.    This,  combined  with  the  most  careful  mechanical  execution,  and  its  very  durable  bind 
ing  renderf ,  it  one  of  the  cheapest  works  accessible  to  the  profession.    Every  subject  properly 
belonging  to  the  lomain  of  surgery  is  treated  in  detail,  so  that  the  student  who  possesses  this 
work  may  be  said  to  have  in  it  a  surgical  library. 

elition  of  Grog's  "  Surgery,"  will  confirm  his  title  of 


We  have  now  brought  our  tusk  to  a  conclusion,  and 
have  seldom  read  a  work  with  the  practical  value  of 
which  we  have  been  more  impressed.  Every  chapter  is 
so  concisely  put  together,  that  the  busy  practitioner, 
when  in  difficulty,  can  at  once  find  the  information  he 
requires.  His  work,  on  the  contrary,  is  cosmopolitan, 
the  surgery  of  the  world  being  fully  represented  in  it. 
The  work,  in  fact,  is  so  historically  unprejudiced,  and 
so  eminently  practical,  that  it  is  almost  a  false  compli- 
ment to  say  that  we  believe  it  to  be  destined  to  occupy 
a  foremost  place  as  a  work  of  reference,  while  a  system 
of surzery  like  the  present  system  of  surgery  is  the 
practice  of  surgeons.  The  printingand  binding  of  the 
work  is  unexceptionable;  indeed.it  contrasts,  in  the 
latter  reject,  remarkably  with  English  medical  and 
surgical  cloth-bound  publications,  which  are  generally 
so  wretchedly  stitched  as  to  require  re-binding  before 
they  are  any  time  in  use. — Dub.  Journ.  of  Med.  Sci.. 
March,  1874. 

Dr.  Gross's  Surgery,  a  great  work,  has  become  still 
greater,  both  in  size  and  merit,  in  its  most  recent  form. 
The  difference  in  actual  number  of  pages  is  not  more 
than  [30,  but.  the  size  of  the  page  having  been  in- 
creased to  what  we  believe  is  technically  termed  ••ele- 
phant." there  has  been  room  for  considerable  additions. 
which,  together  with  the  alterations,  are  improve- 
ments.— Land.  Lancet,  Nov.  16, 1872. 

It  combines,  as  perfectly  as  possible,  the  qualities  of 
a  text-book  and  work  of  reference.  We  think  this  last 


Primut  intta-  Par»t."  It  is  learned,  scholar-like,  n  e- 
thodical,  precise,  and  exhaustive.  We  scarr<  iy  think 
any  living  man  could  write  so  complete  and  faultless  a 
treatise,  or  comprehend  more  solid,  instructive  matter 
in  the  given  number  of  pages.  The  labor  must  have 
been  immense,  and  the  work  gives  evidence  of  i-rt-nt 
powers  of  mind,  and  the  highest  order  of  intellect  i;al 
discipline  and  methodical  disposition,  and  arrangement 
of  acquired  knowledge  and  personal  experience. — A.I*. 
Med.  Journ.,  Feb.  1873. 

As  a  whole,  we  regard  the  work  as  the  representative 
"System  of  Surgery"  in  the  English  language. — Si- 
Louis  Medical  and  Surg.  Journ.,  Oct.  1872. 

The  two  magnificent  volumes  before  us  afford  a  veiy 
complete  view  of  the  surgical  knowledge  of  the  day. 
Some  years  ago  we  had  the  pleasure  of  presenting  the 
first  edition  of  Gross's  Surgery  to  the  profession  as  a 
work  of  unrivalled  excellence;  and  now  we  have  the 
result  of  years  of  experience,  labor.and  study,  all  con- 
densed upon  the  great  work  before  us.  And  to  students 
or  practitioners  desirous^f  enriching  theirlilirary  with 
a  treasure  of  reference,  we  can  simply  commend  the 
purchase  of  these  two  volumes  of  immense  research  — 
Cincinnati  Lancetand  Observer,  Sept.  1&72. 

A  complete  system  of  surgery — not  a  mere  text-book 
of  operations,  but  a  scientific  acconntof  surgicul'thnorv 
and  practice  in  all  its  d«nartments. — Brit,  and  For. 
Mod  Chir.  Rev.,  Jan.  1873. 


B 


7  THE  SAME  AUTHOR. 

A    PRACTICAL  TREATISE    ON  THE  DISEASES,  INJURIES, 

and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra.  Third 
Edition,  thoroughly  Revised  and  Condensed,  by  SAMUEL  W.  GROSS,  M.D.,  Surgeon  to 
the  Philadelphia  Hospital.   In  one  handsome  octavo  volume  of  674  pages,  with  170  illus- 
trations: cloth,  $4  50.     (Just  Issued.) 
For  reference  and  general  information,  the  physician   eases  of  the  urinary  organs. — Atlanta  Mtd  Journ., Oc'. 

orsurgeon  can  find  nowork  that  meets  their necessitiet   1876. 

more  thoroughly  than  this,  a  revised  edition  of  an  ex-       u  is  with  plea!!ure  we  DOW  again  take  up  tMs  old 


r.nllent  treatise,  and  no  medical  library  should  be  with- 
out it.  Replete  with  handsome  illustrations  and  good 
ideas,  it  has  the  unusual  advantage  of  being  easily 
comprehended,  by  the  reasonable  and  practical  manner 
in  which  the  various  subjects  are  syhtematized  and 
arranged  We  heartily  recommend  it  to  the  profession 
as  a  valuable  addition  to  the  important  literature  of  dig- 


worh  in  a  decidedly  new  dress.  Indeed,  it  must  be  re- 
garded as  a  new  book  in  very  many  of  its  parts.  The 
chapter?  on  -'Diseases  of  the  Bladder,"  "Prostate 
Body,"  and  "Lithotomy,"  are  splendid  specimens  of 
descriptive  writing;  while  the  chapter  on  "Stricture'' 
is  one  of  the  most  concise  and  clear  that  we  have  ever 
read. — Aetr  York  Med.  Journ.,  Nov.  1876. 


T>r  THE  SAME  AUTHOR. 

A   PRACTICAL  TREATISE    ON   FOREIGN  BODIES    IN   THE 

AIR-PASSAGES.     In  1  voi.  8vo.,  with  illustrations,  pp.  468,  cloth,  $     75. 


TjRUITT  (ROBERT),  M.R.C.S.,  frc. 

THE  PRINCIPLES  AND  PRACTICE  OF  MODERN  SURGERY. 

A  new  and  revised  American,  from  the  eighth  enlarged  and  improved  London  edition.  Illut- 
trated  with  four  hundred  and  thirty -two  wood  engravings.  In  one  very  handsome  octavo 
volume,  of  nearly  700  large  and  closely  printed  pages,  cloth,  $4  00  ;  leather,  $5  00. 


All  that  the  surgical  student  or  practitioner  could 
desire. — Dublin  Quarterly  Journal. 

It  IB  a  moat  admirable  book.  We  do  not  know 
when  we  have  examined  one  with  more  pleasure. — 
Boston  Med.  and  Surg.  Journal. 

In  Mr.  Drnitt'sbook,  though  contalningonly  some 
•even  hundred  pages,  both  the  principles  and  the 


jractice  of  surgery  are  treated,  and  so  clearly  and 
jerspicuonsly,  as  to  elucidateeveryimportanltopic. 
We  nave  examined  thebook  mostthoroughly,  and 
can  say  that  this  nuccese  is  well  merited.  Hit  hook 
moreover,  possesses  the  inestimable  advantages  of 
having  the  subjects  perfectly  well  arranged  atd 
clan-ified  and  of  being  written  in  a  style  at  once 
clear  tnd  succinct. — Am.  Journal  of  Med.  Scitncet. 


HENRY  C.  LEA'S  PUBLICATIONS — (Surgery}. 


A  SHHURST  (JOHN,  Jr.),  M.D., 

Prof,  nf  Clinical  Surge.ry,  Univ  r,f  Pa  ,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia 

THE    PRINCIPLES  AND  PRACTICE  OF  SURGERY.     Second 

edition,  enlarged  and  revised.     In  one  very  large  and  handsome  octavo  volume  of  over 
1000  pages,  with  542  illustrations.     Cloth,  $6;  leather,  $7.     (Just  Ready.) 

Conscientiousness  and  thoroughness  are  two  very  j  Ashhur it's  Surgery  is  too  well  known  ID  this 
marked  trails  of  character  in  the  author  of  this  country  to  require  special  commendation  from  us 
book.  Out  of  these  trails  largely  has  grown  the  Thie,  its  second  edition,  enlarged  and  thoroughly 
success  of  his  mental  fruit  In  the  past,  and  the  pre-  revised,  brings  it  nearer  our  idea  of  a  model  text- 
sent  offer  seems  in  no  wise  an  exception  to  what  has  bo  tk  than  any  recently  published  treatise  Though 
gone  before.  The  general  arrangement  of  the  vol-  :  numerous  additions  have  been  made,  the  size  of  the 
ume  is  the  sameas  in  the  first  edition,  but  everypart  work  is  not  materially  increased  The  main  trouble 
has  been  carefully  revised,  and  much  new  matter  of  text  books  of  modern  times  is  that  they  are  too 
added.— Phila.  Med.  Times,  Feb.  1,  1S79.  •  I  cumbersome.  The  student  needs  a  book  which  will 

furnish  him   the  most  information  in  the  shortest 


ower  of  condensation,  of  accuracy  and  conciseness  guarantee  of  the  popularity  of  this  edition,  which  is 
f  expression  and  thoroughly  good  English,  Prof.  frelsh  from  the  editor  s  hands  with  many  enlarge- 
shhurst  has  no  superior  among  the  surgical  writers  "*••*•  andj  improvements.  The  author  of  this  work 

Is  deservedly  popular  as  an  editor  and  writer,  and 
his  contributions  to  the  literature  of  surgery  hare 
gained  for  him  wide  reputation.  The  volume  now 


jperior  among  the  snrgi 
in  America. — Am.  Practitioner,  Jan.  1879. 

The  attempt  to  embrace  in  a  volume  of  1000  p»ges 
the  whole  field  of  surgery,  general  and  special, 
would  be  a  hopeless  ta-k  unless  through  the  most 
tireless  industry  in  collating  and  arranging,  and 
the  wisest  judgment  in  condensing  and  excluding. 
These  facilities  have  been  abundantly  employed  by 
the  author,  and  he  has  given  us  a  most  excellent 
treatise,  brought  up  by  the  revision  for  the  second 
edition  to  the  latest  date.  Of  course  this  book  is  not 
designed  for  specialists,  but  as  a  course  of  general 
surgical  knowledge  and  for  general  practitioners, 
and  as  a  text-book  for  students  it  is  not  surpassed 
by  any  that  has  yet  appeared,  whether  of  home  or 
foreign  authorship. — N.  Carolina  Med.  Journal, 
Jaa.  1S79. 


&  . 

offered  the  profession  will  add  new  laurels  to  those 
already  won  by  previous  contributions.  We  cau 
only  add  that  the  work  is  well  arrang.  d,  filled  with 
practical  matter,  and  contains  in  brief  and  clear 
language  all  that  is  necessary  U  be  learned  by  the 
student  of  surgery  whilst  in  attendance  upon  lec- 
tures, or  the  general  practitioner  in  hi*  daily  routine 
practice.— M<i.  Med  Journal,  Jan.  1879. 

The  fact  that  this  work  has  reached  a  second  edi- 
tion so  very  soon  after  the  publication  of  the  first 
one,  speak*  more  highly  of  its  merits  than  anything 
we  might  say  in  the  way  of  commendation.  It 
seems  to  have  immediately  gained  the  favor  of  stu- 
dent* and  physicians. — Cincin.  Med.  KKIBS,  Jan.  '79. 


-DRY ANT  (THOMAS],  F.R.C.S., 

•*-*  Surgeon  to  Quy'g  Jfospital. 

THE  PRACTICE  OF  SURGERY.     Second  American,  from  the  Sec- 

ond  and  Revised  English  Edition.  With  Six  Hundred  and  Seventy  two  Engravings  on 
Wood.  In  one  large  and  very  handsome  imperial  octavo  volume  of  over  1000  large  and 
closely  printed  pages.  Cloth,  $6  ;  leather,  $7.  (Just  Ready.) 

This  work  has  enjoyed  the  advantage  of  two  thorough  revisions  at  the  hand  of  the  author  since 
the  appearance  of  the  first  American  edition,  resulting  in  a  very  notable  enlargement  of  size  and 
improvement  of  matter.  In  England  this  has  led  to  the  division  of  the  work  into  two  volumes, 
which  are  here  comprised  in  one,  the  size  being  increased  to  a  large  imperial  octavo,  printed  on 
a  condensed  but  clear  type.  The  series  of  illustrations  has  undergone  a  like  revision,  and  will 
be  found  correspondingly  impro\ed. 

The  marked  success  of  the  work  on  both  sides  of  the  Atlantic  shows  that  the  author  has  suc- 
ceeded in  the  effort  to  give  to  student  and  practitioner  a  sou  ad  and  trustworthy  guide  in  the 
practice  of  Surgery;  while  the  simultaneous  appearance  of  the  present  edition  in  England  and 
in  this  country  affords  to  the  American  reader  the  benefit  of  the  most  recent  advances  made 
abroad  in  surgical  science.  t 

There  are  so  many  text-books  of  surgery,  so  many 
written  by  skilled  and  distinguished  bauds,  that  to  ob 
tain  the  honor  of  a  third  edition  in  Euglaud  is  no  light 
praise.  Mr.  Bryant  merits  this,  by  clearness  of  style, 


and  good  judgment  in  selecting  the  operations  he  re- 
commends, in  his  new  editions  he  goes  carefully  over 
the  i  Id  grounds,  in  light  of  later  research.  On  these 


Another  edition  of  this  manual  having  been  called 
for,  the  author  has  availed  himself  of  the  opportunity 
to  make  no  few  alterations  in  the  substance  as  well 
as  in  the  arrangement  of  the  work,  and,  with  a  view 
to  its  improvement,  has  recast  the  materials  and  re- 
vised the  whole.  We  onrselven  are  of  the  opinion 
there  is-  no  better  work  on  surgery  extant  — 


,  . 

and  many  allied  points,  Mr.  Bryant  is  a  calm  and  un-  |  Cincinnati  Med.  News,  March,  1879 


partisan  'observer,  and  his  book  throughout  has  the 
great  merit  of  maintaining  the  true  scientific,  judicial 
tone  of  mind.— Mtd.  and  Surg.  Reporter,  March  22, 
1879. 

The  work  before  us  is  the  American  reprint  of  the 


Bryant's  Surgery  has  been  favorably  received  from 
the  first,  and  evidently  grows  in  the  esteem  of  the 
profession  With  each  succeeding  edition.  In  glanc- 
ing over  the  volume  before  us  we  find  proof  in  almost 
every  chapter  of  the  thorough  revision  which  the 


last  London  edition,  and  has  the  advantage  over  the  work  his  undergone,  rnmy  parts  having  be*n  cut 
latter  in  being  of  more  convenient  size,  and  in  being  |  out  and  replaced  by  matter  entirely  fresh.— N.  T. 
compressed  into  one  volume.  The  author  has  rewrit-  Med.  Journ.,  April,  1879. 


ten  the  greater  part  of  the  work,  and  has  succeeded, 
in  the  amount  of  new  matter  added,  in  making  it  mark- 
edly distinctive  from  previous  ediiions.  A  few  extra 
pages  have  been  added,  and  also  a  few  new  illustrations 
introduced.  The  publishers  have  /presented  the  work 
in  a  creditable  style.  As  a  conci.-e  and  practical  manual 
of  British  surgery  it  is  perhaps  without  an  equal,  aud 
will  doubtless  always  be  a  favorite  text-book  with  the 
student  and  pracatiouer. — -<Y.  Y.  iteU.  Rteord,  March 
22,  1879. 


Welcome  as  the  new  edition  is,  and  as  much  as  it 
is  entitled  to  commendation,  yet  its  appearance  at 
this  time  is,  in  a  certain  seu«e,  a  matter  of  regre:,  as 
it  will  be  in  competition  with  another  work,  lately 
issued  from  the  s<me  piess.  But,  the  difficult  ta-k 
of  forming  a  judgment  as  to  the  relative  merits  of 
Bryant  aud  Ashuum  we  will  not  attempt,  but  pre- 
dict that,  considering  the  high  excellence  of  both, 
many  others  will  likewise  be  turced  to  hesitate  long 
in  uiitkiug  choice  between  theiu  — Cincinnati  Lan- 
cet and  Ctiniu,  il^icu  22,  ls<9. 


23 


HENRY  C.  LEA'S  PUBLICATIONS — (Surgery). 


JjJRICHSEN  (JOHN  E.), 

Professor  of  Surgery  in  University  College,  London,  etc. 

THE  SCIENCE  AND  ART  OP  SURGERY;  being  a  Treatise  on  Bur- 

gical  Injuries,  Diseases,  and  Operations.  Carefully  revised  by  the  author  from  the 
Seventh  and  enlarged  English  Edition.  Illustrated  by  eight  hundred  and  sixty  two  en- 
gravings on  wood.  In  two  large  and  beautiful  octavo  volumes  of  nearly  2000  pages  : 
cloth,  $8  50  ;  leather,  $10  50.  (Now  Ready.) 

In  revising  this  standard  work  the  author  has  spared  no  pains  to  render  it  worthy  of  a  continu- 
ance of  the  very  marked  favor  which  it  has  so  long  enjoyed,  by  bringing  it  thoroughly  on  a 
level  with  the  advance  in  the  science  and  art  of  surgery  made  since  the  appearance  of  the 
last  edition.  To  accomplish  this  has  required  the  addition  of  about  two  hundred  pages  of  text, 
while  the  illustrations  have  undergone  a  marked  intprovement.  A  hundred  and  fii'ty  additional 
wood-cuts  have  been  inserted,  while  about  fifty  other  new  ones  have  been  substituted  for  figures 
which  were  not  deemed  satisfactory.  In  its  enlarged  and  improved  form  it  is  therefore  pre- 
sented with,  the  confident  anticipation  that  it  will  maintain  its  position  in  the  front  rank  of 
text-books  for  the  student,  and  of  works  of  reference  for  the  practitioner,  while  its  exceedingly 
moderate  price  places  it  within  the  reach  of  all. 


The  seventh  edition  is  before  the  world  as  the  last 
word  or  surgical  science.  There  may  be  monographs 
which  excel  it  upon  certain  points,  but  as  a  con- 
spectus upon  surgical  principles  and  practice  it  is 
unrivalled.  It  will  well  reward  practitioners  to 
read  it,  for  it  has  been  a  peculiar  province  of  Mr. 
Erichsen  to  demonstrate  the  absolute  interdepend- 
ence of  medical  and  surgical  science  We  need 
scarcely  add,  in  conclusion,  that  we  heartily  com- 
mend the  work  to  students  that  they  may  be 
grounded  in  a  sound  faith,  and  to  practitioners  as 
an  invaluable  guide  at  the  bednide. — Am  Practi- 
tioner, April,  1878. 

It  is  no  idle  compliment  to  say  that  this  is  the  oest 
edition  Mr.  Erichsen  has  ever  produced  of  his  well- 
known  book.  Besides  inheriting  the  virtues  of  i's 
predecessors,  it  possesses  excellences  quite  its  own. 
Having  stated  that  Mr.  Erichsen  his  incorporated 
into  this  edition  every  recent  improvement  in  the1 
science  and  art  of  surgery,  it  would  be  a  supereroga- 
tion to  give  a  detailed  criticism.  In  short,  we  un- 
hesitatingly aver  that  we  know  of  no  other  single 
work  where  the  student  and  practitioner  can  gain  at 
once  so  clear  an  insight  in  to  the  principles  of  surgery, 
and  so  complete  a  knowledge  of  the  exigencies  of 
surgical  practice.—  London  Lancet,  Feb.  14,  1878 

For  the  past  twenty  years  Erichsen's  Surgery  has 
maintained  its  place  as  the  leading  text-book,  not  only 
in  this  country,  but  in  Great  Britain.  That  it  is  able 
to  hold  its  ground,  is  abundantly  proven  by  the  tho- 
roughness with  which  the  present  edition  has  been 
revised,  and  by  the  large  amount  of  valuable  mate- 
rial that  has  been  added.  Aside  from  this,  cne  hun- 
dred and  fifty  new  illustrations  have  been  inserted, 
including  quite  a  number  of  microscopical  appear- 
ances of  pathological  processes.  So  marked  is  this 
change  for  the  better,  that  the  work  almost  appears 
as  an  entirely  new  one. — 3fed.  Record,  Feb.  23,1878. 


Of  the  many  treatises  on  Surgery  which  it  has  been 
our  task  to  study,  or  our  pleasure  to  read,  there  is  noue 
which  in  all  points  has  satisfied  us  so  well  as  the  classic 
treatise  of  Erichsen.  His  polished,  clear  style,  his  free- 
dom from  prejudice  and  hobbies,  his  unsurpassed  grasp 
of  his  suhject,  and  vast  clinieal  experience,  qualify  him 
admirably  to  write  a  model  text-book.  When  we  wish, 
at  the  least  cost  of  time,  to  learn  the  most  of  a  topic  in 
surgery,  we  turn,  by  preference,  to  his  work.  It  is  a 
pleasure,  therefore,  to  see  that  the  appreciation  of  it  is 
general,  and  has  led  to  the  appearance  of  anoiher  edi- 
tion.— Alfd.  and  Surg.  Reporter,  i'eb.  2, 1878. 

Notwithstanding  the  increase  in  size,  we  observe  that 
much  old  matter  has  been  omitted.  The  entire  work 
has  been  thoroughly  written  up.  and  not  merely  amend- 
ed by  a  few  extra  chapters  A  great  improvement  has 
been  made  in  the  illustrations.  One  hundred  and  fifty 
new  ones  have  been  added,  and  many  of  the  old  ones 
have  been  redrawn  The  author  highly  appreciates  the 
favor  wilh  which  his  work  has  been  received  by  Ameri- 
can surgeons,  and  has  endeavored  to  render  bis  latest 
edition  more  than  ever  worthy  of  their  approval.  That 
he  has} succeeded  admirably,  must,  we  tiiiuk.  be  the 
general  opinion.  We  heartily  recommend  the  book  to 
both  student  and  practitioner. — N.  Y.Aled.  Journal, 
Feb.  1878. 

Erichsen  has  stood  so  prominently  forward  for 
years  as  a  writer  on  Surgery,  that  his  reputation  is 
world  wide,  and  his  name  is  as  familiar  to  the  med- 
ical student  as  to  the  accomplished  and  experienced 
surgeon.  The  work  is  not  a  reprint  of  former  edi 
lions,  but  has  in  many  places  been  entirely  rewrit- 
ten. Recent  improvements  in  surgery  have  not  es- 
caped his  notice,  various  new  operations  have  been 
thoroughly  analyzed,  and  their  merits  thoroughly 
discussed.  One  hundred  and  fifty  new  wood-cuts 
add  to  the  value  of  this  work. — N.  0.  Med.  and  Surg. 
Journal,  March,  1878. 


H 


OLMES  (TIMOTHY),  M.D., 

Surgeon  to  St.  George's  Hospital,  London. 

SURGERY,  ITS  PRINCIPLES  AND  PRACTICE.     In   one  hand- 

some  octavo  volume  of  nearly  1000  pages,  with  411  illustrations.  Cloth,  $6;  leather,  $7. 
(Just  Issued.) 

itsforceand  distinctness.— AM".  M«d.  Record,  April 
14,  1876. 

It  will  be  found  a  most  excellent  epitome  of  sur- 
gery by  the  geueral  practitioner  who  ha*  not  the 
time  togiveattention to  more  minute  and  extended 
works  and  to  the  medical  student.  In  fact,  we  know 
of  no  one  we  can  more  cordially  recommend.  The 
author  has  succeeded  well  in  giving  a  plain  and 
practical  account  of  each  surgical  injury  and  dis- 
ease, and  of  the  treatment  which  is  most  com- 
monly advisable.  It  will  no  doubt  become  a  popu- 
lar work  in  the  profession,  and,especially  as  a  text- 
book.— Cincinnati Med.  News,  Aj>ril,  1S76. 


sides  ofthe  Atlantic  with  much  interest.  Mr.  Holmes 
is  a  surgeon  ot  large  and  varied  experience,  and  one 
of  the  best  known,  and  perhaps  the  most  brilliant 
writer  npon  surgical  subjects  in  England.  It  is  a 
book  for  students — and  an  admirable  one — and  for 
the  busy  general  practitioner.  It  will  give  a  student 
all  the  knowledge  needed  to  pass  a  rigid  examina- 
tion. The  book  fairly  justifies  the  high  expectations 
that  were  formed  of  it.  Its  style  is  clear  aud  forcible, 
even  brilliant  at  times,  and  the  conciseness  needed 


A8TITON  ONTHE  DISEASES,  INJURIES.  AKD  MAL- 
FORMATIONS OF  THE  RECTUM  AND  ANUS: 
with  remarks  on  Habitual  Constipation.  Second 
A,m«riean,  from  the  fourth  and  enlarged  London 
Edition.  With  illustrations.  In  one  8vo  vol.ol 
28/  pages,  eloth  ,*3  25. 


SARGENT  ON  BANDAGING  AND  OTHER  OPERA- 
TIONS OF  MINOR  SURGERY.  New  edition,  with 
an  additional  chapter  on  Military  Surgery.  One 
12tno.  vol.  of  SSSpagss,  withlSi  wood-cuts.  Cloth, 
$1  75. 


HENRY  C.  LEA'S  PUBLICATIONS— (Ophthalmology}.  29 

IJAMILTON  (FRANK  H.),  M.D., 

*••*•  Professor  of  Fractures  and  Dislocations,  Ac.,  in  Bellevue  Hasp.  3fed.  College,  New  Fork 

A  PRACTICAL  TREATISE  ON   FRACTURES  AND  DISLOCA- 
TIONS. Fifth  edition,  revised  and  improved.  In  one  large  and  handsome  octavo  volume 
of  nearly  800  pages,  with  344  illustrations.  Cloth,  $5  75  :  leather,  $6  75.  (Lately  Issued.) 
This  work  is  well  known,  abroad  as  Well  as  at  home,  as  the  highest  authority  on  its  important 
subject — an  authority  recognized  in  the  courts  as  well  as  in  the  schools  and  in  practice — and 
again  manifested,  not  only  by  the  demand  for  a  fifth  edition,  but  by  arrangements  now  in  pro- 
gress for  the  speedy  appearance  of  a  translation  in  Germany.  The  repeated  revisions  which  the 
author  has  thus  had  the  opportunity  of  making  have  enabled  him  to  give  the  most  careful  consid- 
eration to  every  portion  of  the  volume,  and  he  has  sedulously  endeavored  in  the  present  issue, 
to  perfect  the  work  by  the  aid  of  his  own  enlarged  experience,  and  to  incorporate  in  it  whatever 
of  value  has  been  added  in  this  department  since  the  issue  of  the  fourth  edition.     It  will  there- 
fore be  found  considerably  improved  in  matter,  while  the  most  careful  attention  has  been  paid 
to  the  typographical  execution,  and  the  volume  is  presented  to  the  profession  in  the  confident 
hope  that  it  will  more  than  maintain  its  very  distinguished  reputation. 


There  is  no  better  work  on  the  subject  in  existence 
than  that  of  Dr.  Hamilton.  It  should  be  in  the  posses- 
sion of  every  general  practitioner  and  surgeon. —  The 
Am.  Journ.  of  Obstetrics.  Feb.  1876. 

The  value  of  a  work  like  this  to  the  practical  physi- 
cian and  surgeon  can  hardly  be  over-estimated,  and  the 
necessity  of  having  such  a  book  revised  to  the  latest 
dates,  notmeri'lyonaccountoftbepracticalimportance 


of  its  teachings,  but  also  by  reason  of  the  medico-legal 
bearings  of  the  cases  of  which  it  treats,  and  which  have 
recently  been  the  subject  of  useful  papers  by  Dr.  Hamil- 
ton and  others,  is  sufficiently  obvious  to  every  one.  The 
present  volume  seems  to  amply  fill  all  the  requisites. 
We  can  safely  recommend  it  as  the  best  of  its  kind  in 
the  English  language,  and  not  excelled  in  any  other  — 
Journ.  of  Nervous  and  Menial  Disease,  Jan.  1876. 


DROWNS  (EDGAR  A.), 

Surgeon  to  the  Liverpool  Eye  and  Ear  Infirmary,  and  tothe  Dispensary  for  STcin  Diseases. 

HOW  TO  USE  THE  OPHTHALMOSCOPE.     Being  Elementary  In- 

structionsin  Ophthalmoscopy,  arranged  for  the  Use  of  Students.    With  thirty -five  illustra- 
tions.    In  one  small  volume  royal  12mo.  of  120  pages  :  cloth,  $1.     (Now  Ready.) 
This  capital  little  work  should  be  in  the  hands  of  i  could  scarcely  fail  of  understanding  them.    Equally 
ev^ry  medical  student,  and  we  had  almostsaid  every  |  satisfactory  are  the  directions  for  the  use  of  the  in- 
general  practitioner.     Its  explanation  of  the  optic*!  ;  strnment  and  the  suggestions  to  aid  in  interpreting 
principles  on  which  the  ophthalmoscope  is  founded,  •  what  is  seen. — Detroit  tfed.  Journ.,  liov.  1S77. 
is  BO  clear  and  simple  that  the  most  stupid  reader  j 

flARTER  (R.  BRUDENELL),  F.R.C.S., 

Ophthalmic  Surgeon  to  St.  George's  Hospital,  etc. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EYE.  Edit- 
ed, with  test-types  and  Additions,  by  JOHN  GREEN,  M.D.  (of  St.  Louis,  Mo.).  In  one 
handsome  octavo  volume  of  about  500  pages,  and  124  illustrations.  Cloth,  $3  75.  (Just 
Issued. ) 

It  would  be  difficult  for  Mr.  Carter  to  write  an  unin-  .  manner,  easy  of  comprehension,  and  hence  the  more 
gtructive  book,  and  impossible  for  him  to  write  an  un-  j  valuable.   We  would  especially  commend,  however,  as 


interesting  one.  Even  on  subjects'  with  which  he  is  not 
bound  to  be  familiar,  hecan  discourse  with  a  rare  degree 
of  clearness  and  effect.  Our  readers  will  therefore  not 
be  surprised  to  learn  that  a  work  by  him  on  the  Diseases 

of  th 


worthy  of  high  praise,  the  manner  iu  which  the  thera 
peutics  of  disease  of  the  eve  is  elaborated,  for  here  the 
author  is  particularly  clear  and  practical,  where  other 
writers  are  unfortunately  too  often  deficient.  The  final 


alik 
do, 


the  Kye  makes  a  very  valuable  addition  to  ophthal-  |  chapter  is  devoted  to  a  discussion  of  the  usesand  selec- 
ic  literature  .  .  .  The  book  will  remain  one  useful  tion  of  spectacles,  and  is  admirably  compact,  plain,  and 
ike  to  the  treneral  and  the  special  practitioner.— Lon  \  useful,  especially  the  paragraphs  on  the  treatment  of 
n  fnnrrt  Oct  30  1875  i  presbyopia  and  myopia.  In  conclusion,  our  thanks  are 

nianctf,Oct.dU,18/a.  j  ^  t£/autnor  fo£ manyu8efui  hintsin  the  greatsub- 


It  is  with  great  pleasure  that  we  can  endorse  the  work 
as  a  most  valuable  contribution  to  practical  ophthal- 
mology. Mr.  Carter  never  deviates  from  the  end  he  has 


in  view,  and  presents  the  s  ubject  in  a  clear  and  conci  se  |  Qct  23, 1875. 


ject  of  ophthalmic  surgery  and  therapeutics,  afield 
where  of  late  years  we  glean  but  a  few  grains  of  sound 
wheat  from  a  massof  chaff. — New  York  Medical  Recvrd, 


(J.SOELBERG), 

Professor  of  Ophthalmology  in  King's  College  Hospital,  Ac. 

A  TREATISE  ON    DISEASES  OF  THE  EYE.     Third  American, 

from  the  Fourth  and  Revised  London  Edition,  with  additions  ;  illustrated  with  numerous 
enzravings  on  wood,  and  six  colored  plates.  Together  with  selections  from  the  Test-types 
of  Jaeger  and  Snellen.  In  one  large  and  very  handsome  octavo  volume.  (Preparing.) 

T  A  URENCE  (JOHN  Z.),  F.R.C.S., 

•*-*  Editor  of  the  Ophthalmic  Review,  *c 

A  HANDY-BOOK  OF  OPHTHALMIC  SURGERY,  for  the  use  of 

Practitioners,  Second  Kdition,  revised  and  enlarged.  With  numerous  illustrations.  In 
one  very  handsome  octavo  volume,  cloth,  $2  7 

TAWSON  (GEORGE),  F.R.C.S.  EngL, 

L*  Assistant  Surgeon  to  the.  Royal  London  Ophthalmic  Hospital,  Meorfield*,  Ac. 

TNTTTRIES  OF  THE  EYE,  ORBIT,  AND  EYELIDS:  their  Imme- 
diate and  Remote  Effects.  With  about  one  handred  illustrations.  In  cne  very  hand- 
some octavo  volume,  clotb,  $3  50. 


30 


HENRY  C.  LEA'S  PUBLICATIONS — (Medical  Jurisprudence). 


TDURNETT  (CHARLES  H.),  M.A  ,M.D., 

J-)  Aurjtl  Surg.  to  the  Pre»b.  Hotp.,  Surgeon-in-iharye  ofthrlnjlr  for  Dig.  of  the  Ear,  Phila. 

THE    EAR,  ITS    ANATOMY,   PHYSIOLOGY,  AND    DISEASES. 

A  Practical  Treatise  for  the  Use  of  Medical  Students  and  Practitioners.  In  one  hand- 
some octavo  volume  of  615  pages,  with  eighty-seven  illustrations  :  cloth,  $4  50  ;  leather, 
$5  50.  (Just  Ready.) 

Recent  progress  in  the  investigation  of  the  structures  of  the  ear,  and  advances  made  in  the 
modes  of  treating  its  diseases,  wouldseem  to  render  desirable  a  new  wovk  in  which  all  the  re- 
sources of  the  most  advanced  science  should  b«>  placed  at  the  disposal  of  the  practitioner.  This 
it  has  been  the  aim  of  Dr.  Burnett  to  accomplish,  and  the  advantages  which  he  has  enjoyed  in 
the  special  study  of  the  subject  are  a  guarantee  that  the  result  of  his  laboris  will  prove  of  service 
to  the  profession  at  large,  as  well  as  to  the  specialist  in  this  department. 


On  account  of  the  great  advances  which  have  been 
made  of  late  years  in  otology,  and  of  the  increased 
intf  rest  manifested  in  it,  the  medical  profession  will 
welcome  this  new  work,  which  presents  clearly  and 
concisely  its  present  aspect,  whilst  clearly  indi- 
cating the  direction  in  which  further  researches  can 
be  most  profitably  carried  on.  Dr.  Barn-  tt  from  hie 
own  matured  experience,  and  availing  himself  of 
the  observations  and  discoveries  of  others,  has  pro- 
duced a  work,  which  as  a  text-book,  stands  facile 
princtps  in  our  language.  We  had  marked  several 
pa-sages  as  well  worohy  of  quotation  and  the  atten- 
tion of  the  general  practitioner,  but  their  number  and 
the  space  at  onr  command  forbid.  Perhaps  it  is  bet- 
ter, as  the  book  ought  to  be  in  the  hands  of  every 
medical  student,  and  its  study  will  well  repay  the 
busy  practitioner  in  the  pleasure  he  will  derive  from 
the  agreeable  style  in  which  many  otherwise  dry 


As  the  title  of  the  work  indicates,  this  volume 
treats  of  the  anatomy  and  physiology  of  the  ear,  a« 
well  an  of  its  diseases,  and  the  author  has  taken 
special  pains  to  make  thisditlicult  and  complicated 
matter  thoroughly  clear  and  intelligible  The  book 
is  desigued  especially  for  the  use  of  students  and 
general  practitioners,  and  places  at  their  disposal 
much  valuable  material.  Such  a  book  as  the  pre- 
sent one,  we  think,  has  long  been  needed,  and  we 
may  congratulate  the  author  on  his  success  in  fill- 
iug  the  gap.  Both  s-.udent  and  practitioner  can 
ttndy  the  work  with  a  great  deal  of  benefit.  It  is 
profu-ely  and  beautifully  illu»trated.— A'.  Y.  Hot- 
pital  Gazette,  Oct  15,  1877. 

The  appearance  of  this  book  is  another  proof  of th» 
rapidly  increasing  amount  <>f  hone«t,  valuable  work 
that  is  now  being  done  in  the  various  branches  of 


and  mostly  unknown  subjects  are  treated.  To  the  medical  scienceiu  this  country.  Dr.  Burneit  is  to  be 
specialist  the  work  is  of  the  highest  value,  and  his  j  commended  for  having  written  the  best  book  ou  the 
sense  of  gratitude  to  Dr.  Burnett  will,  we  hope,  be  j  subjpct  in  the  English  language,  and  especially  for 
proportionate  to  the  amount  of  benefit  lie  can  obtain  j  the  care  and  attention  he  has  given  to  the  scientific 
from  the  careful  study  of  the  book,  and  a  constant  |  side  of  the  subject. — N.  Y.  Mem.  Jaurn.,  Dec.  1S77. 
reference  to  its  trustworthy  pages. — Edinbu.  gh 
lied.  Jour.,  Aug.  1878. 

rFAYLOR  (ALFRED    S.),M.D., 

£  Lecturer  on  Jfed.  Juritp.  and  Ghemittry  in  Ouy't  Hospital. 

POISONS  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.     Third  American,  from  the  Third  and  Revised  English  Edition.     In  one 
large  octavo  volume  of  850  pages  ;  cloth,  $5  50  ;  leather,  $6  50.     (Just  Issued.) 
The  present  is  based  upon  the  two  previous  edi-    being  described  which  give  rise  to  Isgai  investiga- 


tions; "but  the  complete  re  vision  rendered  necessary 
by  time  has  converted  it  into  a  new  work."  This 
statement  from  the  preface  contains  all  that  it  is  de- 
sired to  know  in  reference  to  the  new  edition  The 
works  of  this  author  are  already  in  the  library  of 
every  physician  who  is  liable  to  be  called  upon  for 
medieo-legil  testimony  (and  what  one  is  not?),  so  that 
all  that  is  required  to  be  known  about  the  present 
book  is  that  the  author  has  kept  it  abreast  with  the 
times  What  makes  it  now,  as  always,  especially 
valuable  to  the  practitioner  is  it»  conciseness  and 
practical  character,  only  those  poisonous  substances 


tions.  —  The  Clinic,  Nov.  6,  1S75. 

Dr.  Taylor  hat  brought  to  bear  on  the  compilation 
of  thu  volume,  stores  of  learning,  experience,  and 
practical  acquaintance  with  his  subject,  probably  far 
beyoud  what  any  other  living  authority  ou  toxicol- 
ogy could  have  amassed  or  utilized.  He  has  fully 
sustained  his  reputation  by  the  consummate  skill 
and  legal  acumen  he  l.as  displayed  in  the  arrange- 
ment of  tne  subject-matter,  and  the  re^lt  is  a  work 
ou  Poisons  which  will  b*  indispensable  to  every  stu- 
dent or  practitioner  in  law  and  medicine. — The  Dub- 
tin  Journ.  of  Med  Set.,  Oct.  1S75. 


TOY  THE  SAME  AUTHOR. 

MEDICAL  JURISPRUDENCE.   Seventh  American  Edition.   Edited 

by  JOHH  J.  REESE,  M.D.,  Prcf.  of  Med.  Jurisp.  in  the  Univ.  of  Penn.     In  one  large 
octavo  volume  of  nearly  900  pages.     Cloth,  $5  00;  leather,  $6  00.     (Lately  Issued.} 


It  is  beyond  question  the  most  attractive  as  well 


THE  PRINCIPLES  AND  PRACTICE  OF  MEDICAL  JURISPRU- 

DENCE.     Second  Edition,  Revised,  with  numerous  Illustrations.    In  two  large  octavo 

volumes,  cloth,  $10  00;  leather,  $12  00 

This  great  work  is  now  recognized  in  England  as  the  fullest  and  most  authoritative  treatise  on 
every  department  of  its  important  subject.  In  laying  it,  in  its  improved  form,  before  the  Amer- 
ican profession,  the  publisher  trusts  that  it  will  assume  the  same  position  in  this  country. 


HENRY  C.  LEA'S  PUBLICATIONS — (Miscellaneous). 


31 


THOMPSON  (SIR  HENRY), 

•*•  Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital . 

LECTURES  ON  DISEASES  OF  THE  URINARY  ORGANS.  With 

illustrations  on  wood.     Second  American  from  the  Third  English  Edition.    In  one  neat 
octavo  volume.     Cloth,  $2  25.     (Just  Issued.) 


B 


7  THE  SAME  AUTHOR. 


ON  THE  PATHOLOGY  AND  TREATMENT  OF  STRICTURE  OF 

THE  URETHRA  AND  URINARY  FISTULA.  With  plates  and  wood-cuts.  From  the 
third  and  revised  English  edition.  In  one  very  handsome  octavo  volume,  cloth,  $3  60. 
( Lately  Published.) 

DOBERTS  (WILLIAM),  M.D., 

•*•**  Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  PRACTICAL  TREATISE    ON  URINARY  AND  RENAL  DIS 

EASES,  including  Urinary  Deposits.  Illustrated  by  numerous  cases  and  engravings.  Sec- 
ond American,  from  the  Second  Revised  and  Enlarged  London  Edition.  In  one  large 
and  handsome  octavo  volume  of  616  pages,  with  a  colored  plate  ;  cloth,  $4  50.  (Lately 
Published.) 

TTUKE  (DANIEL  HACK),  M.D., 

J-  Joint  author  of  "  The  Manual  of  Psychological  Medicine,"  ice. 

ILLUSTRATIONS  OF  THE  INFLUENCE  OF  THE  MIND  UPON 

THE  BODY  IN  HEALTH  AND  DISEASE.  Designed  to  illustrate  the  Action  of  the 
Imagination.  In  one  handsome  octavo  volume  of  416  pages,  cloth,  $3  25.  (Lately  Issued.) 


-DLANDFORD  (O.  FIELDING),  M.D.,  F.R.C.P., 

J-J  Lecturer  on  Psychological  Medicine  at  the  School  of  St.  George's  Hospital,  Stc. 

INSANITY  AND  ITS  TREATMENT:  Lectures  on  the  Treatment, 

Medical  and  Legal,  of  Insane  Patients.  With  a  Summary  of  the  Laws  in  force  in  the 
United  States  on  the  Confinement  of  the  Insane.  By  ISAAC  RAY,  M.  D.  In  one  very 
handsome  octavo  volume  of. 471  pages;  cloth,  $3  25. 

It  satisfies  a  want  which  mast  have  been  sorely  i  actually  seen  in  practice  and  the  appropriate  treat 
feltby  the  busygeneralpractitionersof  thiseonntry. }  ment  for  them,  we  find  in  Dr.  Blaxidford's  work  a 
It  takes  the  form  of  a  manual  of  clinical  description  i  considerable  advance  over  previous  writing)-  on  tl  e 
of  the  various  forms  of  insanity,  with  a  description  subject.  His  pictures  of  the  various  forms  of  mect») 


of  the  mode  of  examining  persons  suspected  of  in- 
sanity. We  call  particular  attention  to  this  feature 
of  the  book,  as  givingit  a  unique  value  to  the  gene- 
ral practitioner.  If  we  pass  from  theoretical  conside- 
rations to  descriptions  of  the  varieties  of  insanity  as 


disease  are  so  clear  and  good  that  no  reader  can  fail 
to  be  struck  with  their  superiority  to  those  given  i  n 
iidinary  manuals  in  the  English  language  or  (so  far 
as  our  own  reading  extendsjin  any  other. — London 
Practitioner,  Feb.  1871. 


EA  (HENRY  C.). 

'SUPERSTITION  AND  FORCE:  ESSAYS  ON  THE  WAGER  CF 

LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL,  AND  TORTURE.     Third  Revised 
and    Enlarged   Edition.     In  one  handsome  royal  I2mo.  volume  of  552  pages.     Cloth, 


$2  60.      (Just  Ready  ) 

The  appearance  of  a  new  edition  of  Mr.  Henry  C. 
Lea's  "Superstition  and  Force"  is  a  s.gn  that  our 
highest  scholarthip  is  not  without  honor  in  its  na- 
tire  country.  Mr.  Lea  has  met  every  fresh  demand 
for  his  work  with  a  careful  revision  of  it,  and  the 
present  edition  is  not  only  fuller  and,  if  possible, 
more  accurate  than  either  of  the  preceding,  but, 
from  the  thorough  elaboration  is  more  like  a  har- 
monious concert  and  less  like  a  batch  of  studies. — 
The  Nation,  Aug.  1,  1878. 

Many  will  ba  tempted  to  say  that  this,  like  the 
«'DeclineandFall,"isone  of  the  aucriticizable  books 
Its  facts  ate  innumerable,  its  deductions  simple  and 
inevitable,  and  its  cktvaux-dn-fritie  of  references 
bristling  and  dense  enough  to  make  the  keenest, 
stoutest,  and  best  equipped  assailant  think  twice 
before  advancing.  Nor  is  there  anything  contro- 
versial in  it  to  provoke  assault.  The  author  is  no 


polemic.  Though  be  obviously  feels  and  thicks 
strongly,  he  succeeds  in  attaining  impartiality. 
Wheti  er  looked  on  as  a  picture  or  *  mirror,  a  work 
such  as  this  has  a  lasting  value.— Lipfrincott'f 
Magazine,  Oct.  1S78. 

Mr.  Lea's  curious  historical  monographs ,  of  which 
oue  if  ihe  most  important  is  here  reproduced  in  an 
enlarged  form,  have  given  him  an  unique  position 
among  English  and  American  scholars.  He  is  dis- 
tinguished for  bis  recoudite  and  affluent  learning, 
his  powar  of  exhaustive  historical  analyst*,  tl.e 
breadth  and  accuracy  of  his  researches  among  the 
rarer  sources  of  knowledge,  the  gravity  and  temper- 
ance of  his  statements,  combined  with  singular 
earnestness  of  conviction,  and  his  warm  attachment 
to  the  eau«e  of  human  freedom  and  intellectual  pro- 
gress.—.iV.  ¥.  Tribune,  Aug.  9,  1878. 


TOY  THE  SAME  AUTHOR.    (Late'y  Published.) 

STUDIES  IN  CHURCH  HISTORY— THE  RISE  OF  THE  TEM- 

PORAL  POWER— BENEFIT  OF    CLERGY— EXCOMMUNICATION.     In    one   large 

royal  12mo.  volume  of  516  pp.;  cloth,  $2  75. 

The  story  was  never  told  more  calmly  or  with  .  has  a  peculiarimportauceforthe  English  »tndent,acd 
er-ater learning  or  wiser  thought.  We  doubt,  indeed,  !  Is  a  chapter  on  Ancient  Law  likely  to  be  regarded  as 
ff  any  other  study  of  this  field'can  be  compared  with  !  Inal.  We  can  hardly  pas.  from  our  mention  of  such 
lais  for  clearness,  accuracy,  and  power. -  Chicago  works  as  these-with  which  that  on  Sacerdotal 
Krnn.in.rr  D«c  1870  C  ilibacv"  should  be  i  uelnded— without  notinjr  < ce 

*M™:Sla£.^ 

^ys&srszst  p-er1:  ££«TS  ;  on*-  *.* 

Clergy,  and  Excommunication,  the  record  of  which  I 


32 


HENRY  C.  LEA'S  PUBLICATIONS. 


INDEX   TO    CATALOGUE. 


American  Journal  of  ihe  Medical  Sciences  .  1 
Abstract,  Monthly,  of  the  Med.  Science*  .  .  3 

Allen's  Anatomy  ' 7 

Anatomical  Atlas,  by  Smith  and  Homer  .  .  7 
Abbton  on  Che  Kectnm  and  Anns  .  .  .28 

Attfield's  Chemistry 11 

Aah  well  on  Diseases  of  Females         .        .        .2:3 

Ashhuriit's  Surgery 25 

Browne  ou  Ophthalmoscope 29 

Browne  on  the  Throat IS 

Burnett  ou  the  Ear 30 

Barnes  011  Diseases  of  Women  .  .  .  .22 
Bellamy's  Surgical  Anatomy  1 

Bryant  s  Practical  Surgery  .        .        .        .27 

Bloxam's  Chemistry 11 

Blandford  on  Insanity 31 

Basham  on  Kenal  Diseases 18 

Briuton  on  the  Stomach  ....     18 

Barlow's  Practice  ol  Medicine  .  .  .  .14 
Bowman's  (John  E.)  Practical  Chemistry .  .  10 
Bowman's  (John  E.)  Medical  Chemistry  .  .  10 

Bristowe's  Practice 16 

Bamstead  on  Venereal 19 

Burn  stead  and  Cullerier's  Atlaeof  Venereal  .  10 
Carpenter's  Human  Physiology  .  .  8 

Carpenter  on  the  Use  and  Abuse  of  Alcohol       .    13 

Cornil  and  Rauvier )4 

Carter  on  the  Eye 29 

Cleland's  Dissector 7 

Classen's  Chemistry 10 

Clowes' Chemistry 11 

Century  of  American  Medicine  ....  5 
Chadwick  on  Diseases  of  Women  .  .  .23 
Charcot  on  the  Nervous  System  .  .  .  .17 
Chambers  on  Diet  and  Regimen  ....  18 
Chambers's  Restorative  Medicine  .  .  .  IS 
Christison  and  Griffith's  Dispensatory  .  .  is 
Churchill's  Svstem  of  Midwifery  .  .  .  21 
Churchill  on  Puerperal  Fever  .  .  .  .21 
Condie  on  Diseases  of  Children  .  .  .  .21 
Cooper's  (B.  B.)  Lectures  on  Surgery  .  .  25 
Callerier's  Atlas  of  Venereal  Diseases  .  .  TO 
Cycloptedia  of  Practical  Medicine  .  .  .14 
Dalton's  Human  Physiology  ....  9 

Davis's  Clinical  Lectures 14 

Dewees  on  Diseases  of  Females  .  .  .  .21 
Drnitt's  ModernSurgery  .  ...  26 

Danglison's  Medical  Dictionary  ...  4 
Dunglison's  Human  Physiology  ...  9 
Ehis's  Demonstrations  in  Anatomy  ...  7 
Erichseu'e  System  of  Surgery  .  .  .  .28 
Emmet  ou  Diseases  of  Woineu  .  .  .  .23 
Farquharson's  Therapeutics  .  ...  .11 

Fenwick's  Diagnosis 14 

Finlayson's  Clinical  Diagnosis  .  .  .  .17 
Flint  on  Respiratory  Organs  .  .  .  .  18 

Flint  on  the  Heart 18 

Flint's  Practice  of  Medicine la 

Flint's  Essays 15 

Flint's  Clinical  Medicine 15 

Flint  on  Phthisis IS 

Flint  on  Percussion jg 

Fothergill's  Handbook  ofTre»trnent  .        .     ig 

Fothergill's  Antagonism  of  Therapeutic  Agents  .  16 
F^wnes's  Elementary  Chemistry  .  .  .10 
Fox  on  Diseases  of  the  Skin  .  .  .  .20 
Fuller  on  the  Lungs,  &c.  ...  18 

Green's  Pathology  and  Morbid  Anatomy  .        .     14 

Gibson's  Surgery 25 

Glnge's  Pathological  Histology,  by  Leidy.        .     14 

Gray's  Anatomy 6 

Galloway's  Analysis 10 

Griffith's  (R.  E.)  Universal  Formulary        .        .     12 

Gross  on  Urinary  Organs 26 

Gross  on  Foreign  Bodies  in  Air-Passages  .  .  2ti 
Gross's  Principles  and  Practice  of  Surgery  .  26 

Habershon  on  the  Abdomen 16 

Hamilton  on  Dislocation*  and  Fractures  .  .  29 
Hartshorne's  Essentials  of  Medicine  .  .  i.i 
Hartsnorne's  Conspectus  of  the  Medical  Sciences  fi 
Hartshorne's  Anatomy  and  Physiology  .  .  9 
Hamilton  on  Nervous  Diseases  .  .  .  .17 
Heath's  Practical  Anatomy  ....  7 
Hoblyn's  Medical  Dictionary  ....  4 
Hodge  on  'Women 21 


PAfiS 

Hedge's  Obstetrics 24 

iolland's  Medical  Notes  and  Reflections  .        .     14 

Holmes's  Surgery 28 

Uolden's  Landmarks  tt 

Corner's  Anatomy  and  Histology     ...      7 

Hudson  on  Fever 18 

Hill  on  Venereal  Diseases 19 

Ilillier's  Handbook  of  Skin  Diseases  .  .  20 
/ones  (C.  Handheld)  on  Nervous  Disorders  .  18 

Kirkes'  Physiology 8 

Knapp's  Chemical  Technology  .  .  .  .  11 
Lea's  Superstition  and  Force  .  ...  31 
Lea's  Studies  in  Church  History  .  .31 

Lee  on  Syphilis 19 

Lincoln  ou  Electro-Therapeutics          .        .        .18 
Irishman's  Midwifery  ......     25 

La  Roche  on  Yellow  Fever.        .        •      /'•         •     1* 

La  Roche  on  Pneumonia,  &c 18 

Laurence  and  Moon's  Ophthalmic  Surgery  .  29 
Lawson  on  the  Eye  ...  .29 

Lehmann's  Physiological  Chemistry,  2  vols.  .  9 
Lehmann'e  Chemical  Physiology  ...  9 
Ludlow'e  Manual  of  Examinations  ...  5 

Lyons  on  Fever 18 

Medical  News  and  Library 2 

Meigs  on  Puerperal  Fever 22 

Miller's  Practice  of  Surgery  .  .  .  .23 
Miller's  Principles  of  Surgery  .  .  .  .23 
Montgomery  on  Pregnancy 

Neill  and  Smith's  Compendium  of  Med.  Science  5 
Neligan's  Atlas  of  Diseases  of  the  Skin  .  .  2 

Obstetrical  Journal - 

Parry  on  Extra-Uterine  Pregnancy     .        .        .    2.5 

Pavy  on  Digestion 1 

Pavy  on  Food 1 

Parrish's  Practical  Pharmacy     .        .        .        .     1 

Pirrie's  System  of  Surgery 25 

Playfair's  Midwifery 24 

Quain  and  Sharpey's  Anatomy,  by  Leidy  .        . 
Roberts  on  Urinary  Diseases        .        .        •        .31 
Ramsbotham  on  Parturition         .        .        .        .25 
Remsen's  Principles  of  Chemistry      ...      9 

Rigby's  Midwifery 21 

Rudwell's  Dictionary  of  Science  .        .  .5 

Snmson's  Operative  Surgery  .  .  .  .25 
Swayne's  Obstetric  Aphorisms  .  .  .  .21 

Seller  on  the  Throat 18 

Sargent's  Minor  Surgery       .        .  .        .     28 

Sharpey  and  Quain's  Anatomy,  by  Leidy  . 

Skey's  Operative  Surgery 26 

Slade  on  Diphtheria IS 

Schafer's  Histology 7 

Smith  (J.  L.)  on  Children 21 

Smith  (H.  H.)  and  Homer's  Anatomical  Atlas  .  7 
Smith  (Edward)  on  Consumption  .  .  .18 
Smith  on  Wasting  Diseases  in  Children  .  .  21 

gtille's  Therapeutics 12 

Siille  &  Maisch's  IMspensatory  .  .  .  .13 
Sturges  on  Clinical  Medicine  ....  14 

Stokes  on  Fever .     14 

Tanner's  Manual  of  Clinical  Medicine        .        .      3 

Tanner  on  Pregnancy 24 

Taylor's  Medical  Jurisprudence 

Taylor's  Principles  and  Practice  of  Med    Jnrisp    30 

Taylor  on  Poisons 30 

Tuke  on  the  Influence  of  the  Mind  .  .  .31 
Thomas  on  Diseases  of  Females  .  .  .  .22 
Thompson  on  Urinary  Organs  .  .  .  .31 

Thompson  on  Stricture 31 

Todd  on  Acute  Diseases 14 

Woodbary's  Practice 13 

Walshe  on  the  Heart IS 

Watson's  Practice  of  Physic       ....     13 

Wells  on  the  Eye 29 

West  on  Diseases  of  Females  .  .  .  .20 
West  on  Diseases  of  Children  .  .  .  .20 
West  on  Nervous  Disorders  of  Children  .  .  21 
What  to  Observe  in  Medical  Cases  .  .14 

Williams  on  Consumption 18 

Wilson's  Human  Anatomy 7 

Wilson  on  Diseases  of  the  Skin  .        .  .    20 

Wilson's  Plates  on  Diseases  of  the  Skin  .  .  20 
Wilson's  Handbook  of  Cutaneous  Medicine  .  20 
Wohler's  Organic  Chemistry  ....  9 
Winckel  on  Childbed  .  ....  23 


HENRY  C.  LEA— Philadelphia. 


Date  Due 


CAT.    NO    24    161 


A       r\r\r\ '" " 


WI  100 
HllU  o 

1879' 
Habershon,  Samuel  0 

On  diseases  of  the  abdomen. 


WI  100 
Hill*  o 

1879 
Habershon,  Samuel  0 

On  diseases  of  the  abdomen  , 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


